Methods of treating thyroid eye disease

ABSTRACT

The present invention relates to a methods and compositions for the treatment of and management of symptoms for thyroid eye disease. The methods include administering to a patient having thyroid eye disease an agent that interferes with hyaluronan synthesis in an amount that is effective to inhibit hyaluronan synthesis in a retro-ocular space. The pharmaceutical compositions that includes a carrier suitable for ophthalmic delivery and an agent that interferes with hyaluronan synthesis. Combination therapies are also disclosed.

This application is a divisional of U.S. patent application Ser. No.13/099,991, filed May 3, 2011, and claims the benefit of U.S.Provisional Patent Application Ser. No. 61/330,742, filed May 3, 2010,which are hereby incorporated by reference in their entirety.

This invention was made with government support under grant numberEY017123 awarded by the National Institutes of Health. The governmenthas certain rights in this invention.

FIELD OF THE INVENTION

The present invention relates to methods and compositions for thetreatment of Thyroid Eye Disease.

BACKGROUND OF THE INVENTION

Graves' disease is an autoimmune disorder in which 40-60% of patientsdevelop Graves' ophthalmopathy, also called Thyroid Eye Disease (TED).TED is characterized by expansion of the orbital fat compartment andextraocular muscles (Prabhakar et al., Endocr Rev 24(6):802-835 (2003)).Intense inflammation and infiltration of immune cells, including Tcells, macrophages and mast cells, in the retrobulbar space of TEDpatients are key factors that drive the proliferation anddifferentiation of orbital fibroblasts to adipocytes (Lehmann et al.,PPAR Res, Art. ID. 895901 (2008); Feldon et al., Am J Pathol169(4):1183-1193 (2006)). In addition to the adipogenic potential oforbital fibroblasts, these cells are also key producers of extracellularmatrix glycosaminoglycans (GAG). One of the key pathological findings inTED patients is the over-production and accumulation of the GAGhyaluronan (HA). The extremely hydrophilic nature of HA leads toremarkable increases in tissue volume and to the anterior displacementof the eye, or exophthalmos (Smith et al., J Clin Endocrinol Metab89(10):5076-5080 (2004)), resulting in the disfigurement and visionimpairment (Kuriyan et al., Curr Opin Ophthalmol 19(6):499-506 (2008))characteristic of TED.

HA is synthesized as an acidic, negatively charged, high molecularweight polysaccharide via the actions of hyaluronan synthases (HAS)(Jiang et al., Annu Rev Cell Dev Biol 23:435-461 (2007)), of which thereare three isoforms: HAS1, HAS2 and HAS3. Increased HA synthesis closelycorrelates with the expression levels of HAS (Makkonen et al., J BiolChem 284(27):18270-18281 (2009)), which are themselves induced by growthfactors, cytokines (Makkonen et al., J Biol Chem 284(27):18270-18281(2009); Campo et al., Br J Biomed Sci 66(1):28-36 (2009); Guo et al., JBiol Chem 282(17):12475-12483 (2007)) and prostaglandins (PG) (Honda etal., “Prostaglandin E2 Stimulates Cyclic AMP-mediated HyaluronanSynthesis in Rabbit Pericardial Mesothelioma Cells,” Biochem J.292:497-505 (1993); Fischer et al., Thromb Haemost 98(2)287-295 (2007)).One PG that may have an important implication in TED is PGD₂. PGD₂ is ametabolite of arachidonic acid that is formed by the actions ofcyclooxygenases (Cox) and PGD₂ synthases (PGDS) (Goetzl et al., Faseb J9(11):1051-1058 (1995); Herlong et al., Immunol Lett 102(2):121-131(2006)). Many of the biological actions of PGD₂ are mediated through twoG protein-coupled receptors, DP receptor 1 (DP1) and DP2 (also calledchemoattractant receptor-homologous molecule (CRTH2)) (Boie et al., JBiol Chem 270(32):18910-18916 (1995); Nagata et al., FEBS Lett459(2):195-199 (1999); Kostenis et al., Trends Mol Med 12(4):148-158(2006)). These receptors elicit divergent effects by the coupling toeither Gs (DP1) or Gi (DP2) to elevate cyclic AMP (cAMP) orintracellular calcium (Ca²⁺), respectively. PGD₂ can also spontaneouslyundergo a series of dehydration reactions to form the PGJ family ofprostaglandins, including 15d-PGJ₂, an endogenous ligand for theperoxisome proliferator-activated receptor (PPARγ) (Forman et al., Cell83(5):803-812 (1995); Kliewer et al., Cell 83(5):813-819 (1995)).

Human orbital fibroblasts express PPARγ and PPARγ is crucial for thedifferentiation of fibroblasts to adipocytes. A recent publicationreported that activated human T lymphocytes isolated from patients withTED produce much more PGD₂-derived PGs compared to T cells from healthyindividuals (Feldon et al., Am J Pathol 169(4):1183-1193 (2006)). Mastcells are also a key cellular source of PGs, with PGD₂ being the majorprostanoid released (Feldon et al., Am J Pathol 169(4):1183-1193 (2006);Lewis et al., J Immunol 129(4):1627-1631 (1982)). Mast cells are acentral immune cell in the pathogenesis of TED. Not only is thereintense mast cell infiltration and degranulation (Lauer et al., OphthalPlast Reconstr Surg 24(4):257-261 (2008)) associated with adipocytes(Boschi et al., Br J Ophthalmol 89(6):724-729 (2005)) in TED patients,but co-culture of mast cells with orbital fibroblasts up-regulates HAsynthesis (Smith et al., Endocrinology 140(8):3518-3525 (1999)). Itremains unknown whether this increase in HA production by orbitalfibroblasts is the result of PGD₂ acting via the direct modulation of DPreceptors or via some other means. Further, it would be desirable toidentify therapies for TED that can reliably decrease HA productionwithin the retro-ocular space.

The present invention is directed to overcoming these and otherlimitations in the art.

SUMMARY OF THE INVENTION

A first aspect of the present invention relates to a method of treatingthyroid eye disease that includes administering to a patient havingthyroid eye disease an agent that interferes with hyaluronan synthesisin an amount that is effective to inhibit hyaluronan synthesis in aretro-ocular space.

A second aspect of the present invention relates to a pharmaceuticalcomposition that includes a carrier suitable for ophthalmic delivery andan agent that interferes with hyaluronan synthesis.

The accompanying examples demonstrate for the first time that PGD₂increases HA synthesis in orbital fibroblasts via the induction of HAS2.Pharmacological inhibition of DP1, but not DP2, prevented thePGD₂-induced up-regulation of HA. It is also demonstrated thatinhibition of PGD₂ synthesis by mast cells prevents HA synthesis byorbital fibroblasts. These results have important implications fortherapies directed against treating those afflicted with TED. PreventingPGD₂ synthesis by mast cells and/or DP1 activation on orbitalfibroblasts can reduce the severity of the disease. In addition, theaccompanying examples demonstrate that the PPARγ ligands pioglitazone(Pio) and rosiglitazone (Rosi) suppress TGF-β-induced HA production andHAS activation in human orbital fibroblasts, but quite unexpectedlythrough PPARγ-independent pathways. Pio and Rosi also attenuateTGF-β-mediated T cell adhesion to orbital fibroblasts by decreasing HAsynthesis. Together, these data confirm that various agents thatinterfere with HA synthesis, particularly HA synthesis via HAS2 or DP1signaling, can be used to treat TED or control symptoms thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-C show that PGD₂ and PGJ₂ induce HA synthesis in human orbitalfibroblasts. Confluent strains of human orbital fibroblasts (OF1 andOF2) were cultured in RPMI-1640 with 0.5% FBS for 3 days prior totreatment with PGJ₂, PGD₂ or vehicle (DMSO) for 18 hours. The cellculture media was assayed for HA by an HA ELISA as described in theaccompanying examples. There was a significant increase in HA productionby two strains of orbital fibroblasts following treatment with PGD₂ (1-5μM) (FIG. 1A) and PGJ₂ (2 μM) (FIG. 1B). The experiment was performed intriplicate. *p<0.05, **p<0.01, ***p<0.001 compared to vehicle control;#p<0.05, ###p<0.001, OF1 versus OF2. Results are expressed as themean±SD. FIG. 1C shows an agarose gel HA analysis. Orbital fibroblasts(OF1 and OF2) were cultured in RPMI-1640 with 2% FBS for 3 days and thentreated with 5 μM PGD₂ (D₂) or vehicle (V) for 18 hours and theconditioned media analyzed by agarose gel electrophoresis. Both OF1 andOF2 exhibited basal HA (Lanes 3 and 5, respectively, blue color). Whentreated with PGD₂, there was an increase in color intensity, indicatingincreased HA production (Lanes 4 and 6, compare with Lanes 3 and 5).Streptomyces hyaluronidase-digested sample (HA′ase) (from PGD₂-treatedOF2) was included as a negative control (Lane 7).

FIG. 2 is a graph illustrating the differential induction inhyaluronidase mRNA between two orbital fibroblast strains. cDNA fromorbital fibroblast strains OF1 and OF2 treated with 5 μM PGD₂ or vehicle(Untreated) for 4 hours was assessed by qRT-PCR. There was a significantincrease in mRNA expression for all three hyaluronidase isoforms (HYAL1,HYAL2 and HYAL3) when OF1 was treated with 5 μM PGD₂ (***p<0.0001,compared to Untreated). There was no significant increase in HYAL1-3 inPGD₂-treated OF2 cells (ns, compared to Untreated). The induction ofHYAL1, HYAL2 and HYAL3 mRNA in PGD₂-treated OF1 was significantly higherthan PGD₂-exposed OF2 HYAL expression ($$$p<0.0001, for each respectiveHYAL). Results are expressed as the mean±SD (n=3).

FIGS. 3A-D illustrate the induction of HAS mRNA expression by PGD₂ inhuman orbital fibroblasts. FIG. 3A shows the results of RT-PCR analysis:cDNA from orbital fibroblasts treated with 5 μM PGD₂ or vehicle for 2hours was amplified by RT-PCR and separated on 5% acrylamide gels. Allthree HAS isoforms are expressed in human orbital fibroblasts. Followingtreatment with PGD₂, there was a relative increase in the abundance ofHAS1, HAS2 and HAS3 mRNA. 7S was used as a control. B. qRT-PCR: TotalRNA from orbital fibroblasts treated with 5 μM PGD₂ from 1 to 24 hourswas analyzed by qRT-PCR as described in the accompanying Examples. Therewas a significant increase in HAS mRNA levels (HAS1, HAS2 and HAS3)beginning at 2 hours (***p<0.001 compared to time 0 for each HASisoform). Of the three, HAS1 yielded the greatest increase (2807±213)(FIG. 3B); this increase in HAS1 was significantly greater than HAS2 orHAS3 (###p<0.001) (compare to FIGS. 3C-D). Expression of HAS1 and HAS2remained significantly elevated through 4 hours (*p<0.05) (FIGS. 3B-C).By 16 hours, mRNA for HAS1, HAS2 and HAS3 was not different fromcontrol. Results are expressed as the mean±SD of triplicate samplesperformed on duplicate cultures.

FIGS. 4A-B are graphs illustrating that PGD₂-induced HA production byorbital fibroblasts is dependent on HAS2 expression. For FIG. 4A,orbital fibroblasts were transfected with siRNA for HAS1, HAS2, or acombination as described in the accompanying Examples. The cells werecultured for 24 hours in RPMI-1640 with 0.5% FBS, treated with 5 μM PGD₂for 2 hours and HAS gene levels were analyzed by qRT-PCR. The mRNA forHAS1 and HAS2 in the PGD₂-treated SC siRNA samples was standardized to100 for comparison of gene expression. Each siRNA reduced its targetmRNA expression selectively and significantly (up to 80%). **p<0.01. ForFIG. 4B, orbital fibroblasts transfected with siRNA for HAS1, HAS2 or acombination, were cultured in RPMI-1640 with 0.5% FBS for 24 hour, andthen exposed to 5 μM PGD₂ for 18 hours and HA was analyzed by HA-ELISA.Fibroblasts treated with PGD₂ (black bars) increased HA synthesis.Knock-down of HAS2, but not HAS1, significantly reduced the ability ofPGD₂ to induce HA in human orbital fibroblasts. *p<0.05; **p<0.01compared to PGD₂-treated SC siRNA-transfected; ##p<0.01 untreated SCsiRNA versus untreated HAS2 siRNA; ns, no significance, HAS2 siRNAtransfected, PGD₂-treated fibroblasts versus untreatedSC-siRNA-transfected cells.

FIGS. 5A-G illustrate the ability of PGD₂ and PGJ₂ to induce HAproduction in human orbital fibroblasts via DP1, but not DP2,activation. FIG. 5A illustrates the results of RT-PCR: Human orbitalfibroblasts (OF1 and OF2) and T cells express DP1 and DP2 mRNA. Note thevariability in the expression of DP2 between the two fibroblast strains.FIG. 5B is a Western blot analysis, which revealed that orbitalfibroblasts and T cells express both DP1 and DP2 protein. Membranes werere-probed for GAPDH to ensure equal protein loading. FIG. 5C is a graphillustrating that pharmacological inhibition of DP1, but not DP2, blocksPGD₂ and PGJ₂ induced HA production. Orbital fibroblasts were leftuntreated (vehicle) or were pre-treated with 100 nM of the DP1antagonist MK-0524 (MK) or DP2 antagonist Ramatroban (RAM) for 1 hourwith or without PGD₂ or PGJ₂ for 18 hours and HA ELISA performed. BothPGD₂ and PGJ₂ significantly increased HA production compared tountreated (vehicle) (###p<0.001, ##p<0.01, respectively). Pre-treatmentof orbital fibroblasts with MK significantly decreased the ability ofPGD₂ (**p<0.01) and PGJ₂ (*p<0.05) to induce HA levels. RAM was not ableto prevent PGD₂- and PGJ₂-increased HA levels (#p<0.05, ##p<0.01compared to vehicle control, respectively); ns=not significant comparedto untreated (vehicle). FIGS. 5D-F are graphs illustrating the effect oftreatment with the DP1 agonist BW245C on increased expression of HASmRNA. Orbital fibroblasts were cultured in reduced serum for three daysand exposed to BW245C (10 μM) for the indicated times. There was asignificant increase in HAS1 (fold increase: 329±128; **p<0.01) (FIG.5D) and HAS2 (fold increase 17±0.14; ***p<0.001) (FIG. 5E) at two hourscompared to vehicle control. HAS3 mRNA increased by 6 hours (4.8±0.06;***p<0.01) (FIG. 5F). FIG. 5G is a graph showing that activation of DP1by the selective agonist BW245C induces HA. There was a significantincrease in HA when fibroblasts were treated with 5 and 10 μM BW245C(*P<0.05, **P<0.01) compared to vehicle control. Samples were run induplicate utilizing three separate human orbital fibroblast strains(representative results are shown).

FIGS. 6A-B are graphs showing that PGD₂-induced HA synthesis is throughthe DP1-cAMP signal pathway. FIG. 6A shows that DP1 activation by PGD₂or BW245C increases intracellular cAMP level. Orbital fibroblasts weretreated with PGD₂ or BW245C for up to 60 minutes and intracellular cAMPdetected as described in the Experimental Procedures. There was asignificant increase in cAMP within 15 minutes of treatment with PGD₂compared to vehicle control (*p<0.05). cAMP further increased by 30 and60 minutes (***p<0.001). FIG. 6B shows the ELISA results followingtreatment with forskolin or IBMX, with or without PGD₂ or PGJ2. Culturesof confluent orbital fibroblasts were treated with 5 μM forskolin or 200μM IBMX, with or without 5 μM PGD₂ or 2 μM PGJ₂, for 18 hours and thecell culture supernatant collected for HA ELISA. There was a significantincrease in HA when cells were treated with forskolin, PGD₂ or PGJ₂compared to vehicle-treated (open bar) (*p<0.05, **p<0.01). AugmentingcAMP (via IBMX) in conjunction with PGD₂ or PGJ₂ significantly increasedHA when compared to PGD₂ and PGJ₂ alone (#p<0.05). Results are expressedas the mean±SD.

FIGS. 7A-B demonstrate that PGD₂ production by mast cells is dependenton H-PGDS activity. FIG. 7A is a Western blot of HMC-1 cells, whichindicates the expression of Cox-1 and H-PGDS. Unactivated HMC-1 cells donot express Cox-2. GAPDH was used as a housekeeping protein. FIG. 7B isa graph showing that inhibition of H-PGDS activity ameliorates theproduction of PGD₂ by activated mast cells. HMC-1 cells were treatedwith HQL-79 for 1 hour, followed by activation with A23187 and cellculture supernatant assessed for PGD₂ levels by commercial EIA.Activation of HMC-1 cells with A23187 significantly increased PGD₂production (###, p<0.001, compared to untreated). Inclusion of HQL-79significantly reduced PGD₂ production (***, p<0.001).

FIGS. 8A-C illustrate the ability of mast cell-derived PGD₂ to activateorbital fibroblast production of HA. FIG. 8A is a graph showing theeffects of contact co-culture. Confluent orbital fibroblasts were seededwith HMC-1 cells at a cell ratio of 1:1 for 4 h. The mast cells werethen removed, the fibroblasts were washed, and fresh media was added foranother 18 hours. The media was collected for HA ELISA. Co-culture oforbital fibroblasts with HMC-1 cells significantly increase HA synthesis(**, p<0.001). FIG. 8B is a graph showing the effects of transwellco-culture. HMC-1 cells and confluent fibroblasts were co-cultured in atranswell system, where the fibroblasts and HMC-1 cells were separatedby a 0.4 μm membrane; the HMC-1: orbital fibroblast (OF) ratio was: 5:1,10:1 or 20:1. The conditioned media from both chambers was collected forHA ELISA. There was a significant difference in HA levels between HMC-1(upper chamber, open bars) and orbital fibroblasts (lower chamber, blackbars) (#p<0.05; ###p<0.001). Co-culture of orbital fibroblasts withHMC-1 cells significantly increased HA production only by thefibroblasts (lower chamber) (***p<0.001 compared to no HMC-1 cells).FIG. 8C is a graph showing that inhibition of PGD₂ secretion by HMC-1cells prevents HA production by orbital fibroblasts. HMC-1 cells weretreated with the H-PGDS inhibitor HQL-79 prior to co-culturing (ratio20:1) with orbital fibroblasts. There was a significant increase in HAsynthesis when fibroblasts were cultured with HMC-1 cells (**p<0.01compared to no HMC). This increase in HA was attenuated when PGD₂production in mast cells was prevented by HQL-79 (##p<0.001, HQL-79compared to vehicle).

FIG. 9 is a graph showing that siRNA against orbital fibroblast HAS2prevents mast cell-derived PGD₂ induction of HA. Orbital fibroblastswere transfected with HAS1, HAS2 or scrambled control (SC siRNA) siRNAusing Lipofectamine 2000 (Invitrogen). Following this, the fibroblastswere co-cultured for 24 hours with HMC-1 cells in a transwell system ata ratio of 20:1 (mast cells: orbital fibroblasts) and the mediacollected for HA detection. Untransfected orbital fibroblast co-culturedwith HMC-1 cells significantly increased HA production (***p<0.0001,compare untransfected to untransfected with HMC). Co-culture offibroblasts with HMC-1 cells also induced a significant increase in HAin control siRNA-transfected (SC siRNA) (**p<0.001) and HAS1siRNA-transfected (*p<0.05) orbital fibroblasts. HAS2 siRNA-transfectedorbital fibroblasts failed to increase HA synthesis when co-culturedwith HMC-1 cells (###p<0.0001, compared to untransfected, control siRNAand HAS1 siRNA). Results are expressed as mean±SD (n=4-6).

FIGS. 10A-B show that the PPARγ ligands Pio and Rosi inhibit TGF-β1induced HA production in human orbital fibroblasts. Confluent strains ofhuman orbital fibroblasts were cultured in RPMI-1640 with 0.5% FBS for 3days prior to treatment with different concentrations of Pio or Rosiwith or without 2 ng/ml TGF-β1 for 24 hours (FIG. 10A). The culturemedium (secreted HA), cell trypsin solution (pericellular HA) and celllysate (cellular HA) were assayed by an HA ELISA as described in theExperimental Procedures. TGF-β1 treated samples show a robust inductionof secreted and pericellular HA levels. There was no significant changein intracellular HA levels. The experiment was performed in triplicate.*p<0.05, ***p<0.001 compared to vehicle control (V); #p<0.05,###p<0.001, compared to TGF-β1 treatment; ^p<0.05, ^^^p<0.001, 5 μM Pioversus 10 μM Pio or 10 μM Rosi versus 20 μM Rosi; ns, no significantchanges. Samples were run in duplicate utilizing three separate humanorbital fibroblast strains (representative results are shown). Resultsare expressed as the mean±SD. FIG. 10B is a panel of images showingconfluent orbital fibroblasts cultured in reduced serum for three daysand treated with 2 ng/ml TGF-β1 for 24 hours. Cells were stained withbiotinylated HABP (for HA, green, a, d, g), phalloidin (for F-actin,red, b, e, h) and DAPI (for nucleus, blue). Panels a-c: untreated cells;panels d-f: TGF-β1 treated cells; panels g-i: orbital fibroblasts weretreated with HA′ase before fixation. Panels c, f, i; merged fluorescencewith DAPI staining.

FIG. 11 is a panel of graphs showing that Pio and Rosi inhibit TGF-β1induced HAS1 and HAS2 mRNA expression in human orbital fibroblasts.Total RNA from orbital fibroblasts treated with different concentrationsof Pio or Rosi, with or without TGF-β for 6 hours was analyzed byqRT-PCR as described in the Experimental Procedures. White bar, noTGF-β1; black bars, 2 ng/ml TGF-β1. There was a significant increase inHAS1 and HAS2 mRNA levels (***p<0.001 compared to vehicle control) afterTGF-β1 treatment. HAS3 has no significant change. This increase in HAS1or HAS2 induced by TGF-β1 was significantly inhibited by Pio or Rosi(###p<0.001). Results are expressed as the mean±SD of triplicate samplesperformed on triplicate cultures.

FIG. 12 is a graph showing that Pio and Rosi do not influence humanorbital fibroblast viability. Confluent strains of human orbitalfibroblasts were cultured in RPMI-1640 with 0.5% FBS for 3 days prior totreatment with different concentrations of Pio or Rosi with or without 2ng/ml TGF-β1 for 24 hours. Viability was measured by XTT assay. Resultsshown are representative of 3 independent experiments and are mean±SEM(n=8). No significant differences were observed with any treatment(ANOVA). V: vehicle control.

FIGS. 13A-C demonstrate that neither the irreversible PPARγ antagonistGW9662 nor PPARγ siRNA inhibit Pio and Rosi-mediated suppression of HAsynthesis. FIG. 13A is a graph illustrating relative HA expression fromprimary orbital fibroblasts pretreated with 1 μM GW9662 for 1 hour orleft untreated, and then treated with 2 ng/ml TGF-β1 and either 10 μMPio, or 10 μM Rosi for 24 hours. HA synthesis was analyzed by ELISA.GW9662 does not restore TGF-β stimulated HA synthesis in cells treatedwith Pio or Rosi. Results shown are representative of 3 independentexperiments. **p<0.01, ***p<0.001 compared to TGF-β1 treatment. FIG. 13Bis a graph showing relative PPARγ mRNA expression in orbital fibroblastcultures transfected with PPARγ SMARTpool siRNAs or non-specific controlsiRNA. Forty-eight hours after transfection, the medium was changed andculture continued for 2 days. Total RNA was collected and PPARγ 1 andPPARγ 2 mRNA levels were analyzed by qRT-PCR and normalized to 7S RNA.Results shown are the mean±SD for two independent experiments withtriplicate cultures in each experiment. ***p<0.001, compared to scramblesiRNA. FIG. 13C contains a pair of graphs showing the PPARγ independentmechanism of Pio and Rosi. PPARγ siRNA transfected orbital fibroblastcultures were serum starved and then treated with TGF-β1 with or without10 μM Pio or 10 μM Rosi. Twenty-four hours after treatment, theconditioned medium and cell trypsin solution were collected and HAlevels were analyzed by ELISA. Results shown are the mean±SD for threeindependent experiments with duplicate cultures in each experiment.

FIGS. 14A-B illustrates that TGF-β1 induces human peripheral blood Tcell adhesion to orbital fibroblasts through HA-CD44 interaction. FIG.14A shows the expression of CD3 and CD44 on PBMCs. PBMCs were incubatedwith CD3/CD28 beads in RPMI1640 with 10% FBS medium at 37° C. for 2days. After that, rIL-2 (50 U/ml) was added to the culture and incubatedfor several days according to the cell number. After T-cell expansion,the expression of CD3 and CD44 on the cell surface was examined byflow-cytometry. More than 99% of the enriched cells express CD3 andCD44. FIG. 14B is a graph illustrating the number of T cells bound toTGF-β1 treated orbital fibroblasts. Enriched T cells were fluorescentlylabeled by incubation with calcein-AM. After labeling, some T cells wereincubated with 40 μg/ml monoclonal CD44 antibody. Confluent orbitalfibroblasts were cultured in reduced serum for three days and treatedwith 2 ng/ml TGF-β1 for 24 hours. In some cultures, orbital fibroblastswere treated with 100 mU/ml HA′ase for 1 hour. T cells were added andallowed to adhere for 90 min at 4° C. Plates were washed three times andfluorescence was measured at 535 nm. White bars, fibroblast vehiclecontrol; black bars, fibroblast treated with TGF-β for 24 hours. Therewas a significant increase in T cell adhesion to TGF-β1 treated orbitalfibroblasts (***p<0.001 compared to vehicle control). CD44 antibodyattenuated and HA′ase completely abolished the adhesion of T cells tofibroblasts (###p<0.001 compared to TGF-β1 alone; ^^p<0.01 CD44 antibodyversus isotype). Results are expressed as bound T cell number and arethe mean±SEM (n=6) of one of four experiments.

FIGS. 15A-C are graphs illustrating that TGF-β-induced HA production byorbital fibroblasts and T cell-fibroblast adhesion are dependent uponHAS2 expression. FIG. 15A is a graph showing the effect of TGF-β1 onorbital fibroblasts, which were transfected with siRNA for HAS1, HAS2,or a scramble control (SC) siRNA as described in the accompanyingExamples. The cells were serum starved in RPMI 1640 with 0.5% FBS andtreated with 2 ng/ml TGF-β1 for 6 h, and HAS expression levels wereanalyzed by qRT-PCR. The mRNA for HAS1 and HAS2 in the TGF-β-treated SCsiRNA samples was normalized to 100 for comparison of gene expression.Each siRNA reduced its target mRNA expression selectively andsignificantly (up to 80%). For HA detection in FIG. 15B, HAS1 or HAS2siRNA transfected orbital fibroblasts were exposed to 2 ng/ml TGF-β1 for24 h, and secreted HA and pericellular HA was analyzed by HA ELISA.Knockdown of HAS2, but not HAS1, significantly reduced both secreted HAand pericellular HA in human orbital fibroblasts. **, p<0.01, ***,p<0.001 compared with TGF-β-treated SC siRNA-transfected; AA, p<0.01,^^^, P<0.001, HAS1 siRNA versus HAS2 siRNA-transfected, TGF-β-treatedfibroblasts. FIG. 15C is a graph illustrating the relationship betweenHAS expression and TGF-β1 induced T cell adhesion to orbitalfibroblasts. Orbital fibroblasts were transfected with siRNA for HAS1,HAS2, or a SC siRNA for 24 hours. Then cells were serum starved in RPMI1640 with 0.5% FBS and treated with 2 ng/ml TGF-β1 for 24 hours beforeaddition of Calcein-AM labeled T cells. White bar representsuntransfected control samples; black bars represent 2 ng/ml TGF-β1treated siRNA transfected samples. Only HAS2 siRNA significantlyinhibited TGF-β1 induced T cell adhesion (*, p<0.05, ***p<0.001 comparedto untreated control; ###p<0.001 HAS2 siRNA compared to SC siRNA; ^,P<0.05, HAS1 siRNA versus HAS2 siRNA). Results are expressed as bound Tcell number and are the mean±SEM (n=6) of one of three experiments.

FIGS. 16A-B illustrate the ability of Pio and Rosi inhibit TGF-β1induced peripheral blood T cell adhesion to orbital fibroblasts. FIG.16A is a graph illustrating the effect of Pio and Rosi on TGF-β1 inducedT cell adhesion to orbital fibroblasts. Confluent orbital fibroblastswere cultured in reduced serum for three days and exposed to 2 ng/mlTGF-β1 with or without different concentrations of Pio or Rosi for 24hours. Peripheral T cell adhesion tests were performed as describedpreviously. White bars represent vehicle; black bars represent 2 ng/mlTGF-β1. Both Pio and Rosi significantly inhibited TGF-β1 induced T celladhesion (***p<0.001 compared to vehicle control; ###p<0.001 compared toTGF-β1). Results are expressed as bound T cell number and are themean±SEM (n=6) of one of three experiments. FIG. 16B is a panel ofimages of confluent orbital fibroblast cultures in 8-chamber slides thatwere treated with 2 ng/ml TGF-β1, with or without 10 μM Pio or 10 μMRosi for 24 hours. After the T cell adhesion assay, the cells were fixedand stained with 1 μg/ml Biotinylated HABP for HA (red, panels a, d, g),CD3 monoclonal antibody (green, panels b, e, f) and DAPI (blue). T cellsappear on top of the fibroblasts, which are attached to the cultureslide. Panels c, f, i: merged fluorescence with DAPI staining. Panels a,b, c: cells treated with TGF-β1; panels d, e, f: cells treated withTGF-β1+Pio; panels g, h, is cells treated with TGF-β1+Rosi.

FIG. 17 is a panel of images showing that HA and CD3⁺ T cells arepresent in orbital fat tissue from patients with TED. 10 μm thicksections of frozen Graves' orbital fat tissue were stained for HA withBiotinylated HABP (red, panels a, e), CD44 with anti-CD44 monoclonalantibody (green, panels b, f) and CD3 with anti-CD3 monoclonal antibody(purple, panels c, g). In panel e: addition of exogenous soluble free HAbinds the HABP probe to remove endogenous HA signal. In panels d, h:merged fluorescence with DAPI staining. Representativeimmunofluorescence staining of T cell infiltration into orbital fattissue of a patient with TED is shown.

FIG. 18 is a graph illustrating the ability of 15d-PGJ2 inhibitsTGF-beta induced HA production (***p<0.001 compared to vehicle control).

DETAILED DESCRIPTION OF THE INVENTION

A first aspect of the invention relates to a method of treating thyroideye disease. This method includes administering to a patient havingthyroid eye disease an agent that interferes with hyaluronan synthesisin an amount that is effective to inhibit hyaluronan synthesis in aretro-ocular space.

As described below, in various embodiments of the present invention theagent(s) that interfere with HA synthesis do so via inhibiting theactivity of the enzyme hyaluronan synthase, type 2 (HAS2) or interferingwith DP1 signaling.

According to one embodiment, the agent that interferes with hyaluronansynthesis is RNAi that is specific for the enzyme HAS2.

An important feature of RNAi affected by siRNA is the double strandednature of the RNA and the absence of large overhanging pieces of singlestranded RNA, although dsRNA with small overhangs and with interveningloops of RNA has been shown to effect suppression of a target gene. Inthis specification, it will be understood that in this specification theterms siRNA and RNAi are interchangeable. Furthermore, as is well-knownin this field RNAi technology may be effected by siRNA, miRNA or shRNAor other RNAi inducing agents. Although siRNA will be referred to ingeneral in the specification. It will be understood that any other RNAinducing agent may be used, including shRNA, miRNA or an RNAi-inducingvector whose presence within a cell results in production of an siRNA orshRNA targeted to a target HAS2 transcript.

RNA interference is a multistep process and is generally activated bydouble-stranded RNA (dsRNA) that is homologous in sequence to thetargeted HAS2 gene. Introduction of long dsRNA into the cells oforganisms leads to the sequence-specific degradation of homologous genetranscripts. The long dsRNA molecules are metabolized to small (e.g.,21-23 nucleotide (nt)) interfering RNAs (siRNAs) by the action of anendogenous ribonuclease known as Dicer. The siRNA molecules bind to aprotein complex, termed RNA-induced silencing complex (RISC), whichcontains a helicase activity and an endonuclease activity. The helicaseactivity unwinds the two strands of RNA molecules, allowing theantisense strand to bind to the targeted HAS2 RNA molecule. Theendonuclease activity hydrolyzes the HAS2 RNA at the site where theantisense strand is bound. Therefore, RNAi is an antisense mechanism ofaction, as a single stranded (ssRNA) RNA molecule binds to the targetHAS2 RNA molecule and recruits a ribonuclease that degrades the HAS2RNA.

An “RNAi-inducing agent” or “RNAi molecule” is used in the invention andincludes for example, siRNA, miRNA or shRNA targeted to a HAS2transcript or an RNAi-inducing vector whose presence within a cellresults in production of an siRNA or shRNA targeted to the target HAS2transcript. Such siRNA or shRNA comprises a portion of RNA that iscomplementary to a region of the target HAS2 transcript. Essentially,the “RNAi-inducing agent” or “RNAi molecule” downregulates expression ofthe targeted HAS2 enzyme via RNA interference.

Preferably, siRNA, miRNA or shRNA targeting HAS2 enzyme are used.

Ideally, the method involves the systemic hydrodynamic delivery of theRNAi inducing agent, such as siRNA, miRNA or shRNA etc, to the subject.Non-hydrodynamic systemic delivery methods may also be used.

Other delivery methods suitable for the delivery of the RNAi inducingagent (including siRNA, shRNA and miRNA, etc) may also be used. Forexample, some delivery agents for the RNAi-inducing agents are selectedfrom the following non-limiting group of cationic polymers, modifiedcationic polymers, peptide molecular transporters, lipids, liposomesand/or non-cationic polymers. Viral vector delivery systems may also beused. For example, an alternative delivery route includes the directdelivery of RNAi inducing agents (including siRNA, shRNA and miRNA) andeven antisense RNA (asRNA) in gene constructs followed by thetransformation of cells within the retro-ocular space with the resultingrecombinant DNA molecules. This results in the transcription of the geneconstructs encoding the RNAi inducing agent, such as siRNA, shRNA andmiRNA, or even asRNA and provides for the transient and stableexpression of the RNAi inducing agent in those transformed cells of theretro-ocular space. For example, such an alternative delivery route mayinvolve the use of a lentiviral vector comprising a nucleotide sequenceencoding a siRNA (or shRNA) which targets HAS2. Such a lentiviral vectormay be comprised within a viral particle. Adeno-associated viruses (AAV)may also be used.

Exemplary RNAi specific for HAS2 include, without limitation, HAS2 RNAiavailable from Santa Cruz (e.g., sc-45329, sc-45329-SH), as well as thefollowing sequences: 5′-UUGGAACCACACUCUUUGGd(TT)-3′ (SEQ ID NO: 1) and5′-CCAAAGAGUGUGGUUCCUUd(TT)-3′ (SEQ ID NO: 2) (Sussmann et al., Circ.Res. 94:592-600 (2004), which is hereby incorporated by reference in itsentirety.) Any other suitable RNAi molecules specific for HAS2 can alsobe used in accordance with the present invention.

According to a second embodiment, the agent that interferes withhyaluronan synthesis is a DP antagonist. The term “DP antagonist”(prostaglandin D₂ receptor antagonist or PGD₂ antagonist) meanscompounds that are capable of blocking, inhibiting, reducing orotherwise interrupting the interaction between prostaglandin D₂ and itsreceptor (e.g., DP receptor). The PGD₂ antagonist may be selective(interact preferentially with) for the DP1 receptor or may possessantagonistic effects at one or more other prostaglandin receptors.

Exemplary PGD₂ antagonists include, but are not limited to, compoundsdescribed as having PGD₂ antagonizing activity in PCT PublishedApplications WO97/00853, WO98/25919, WO01/79169, WO03/062200 WO01/66520,WO03/022814, WO03/078409, WO2004/103370, and WO02/094830; EuropeanPatent Applications EP945450, EP944614, and EP 1305286; and U.S.Application Publ. No. 20040220237, 20070244107, and 20080194600, all ofwhich are hereby incorporated by reference in their entirety. Specificexamples of PGD₂ antagonists include compounds L888839, MK0525, MK0524,BWA868C, laropiprant, S-555739,2-[(1R)-9-(4-chlorobenzyl)-8-((R)-methylsulfinyl)-2,3,4,9-tetrahydro-1H-carbazol-1-yl]aceticacid, and2-[(1R)-9-(4-chlorobenzyl)-8-((S)-methylsulfinyl)-2,3,4,9-tetrahydro-1H-carbazol-1-yl]aceticacid. Any other PGD₂ antagonists, whether now known or hereafterdeveloped, can also be utilized in accordance with the presentinvention.

According to a third embodiment, the agent that interferes withhyaluronan synthesis is an agent that interferes with PGD₂ synthesis.Agents that interfere with PGD₂ synthesis include PGD synthase (PGDS)inhibitors. Suitable PGDS inhibitors include, without limitation, RNAispecific for PGDS (e.g., HSH007661 from GeneCopoeia, shRNA productNM_014485 from Sigma-Aldrich, and shRNA product TG315682 in pGFP-V-RSvector available from OriGene), and compounds as described in U.S.Patent Application Publ. No. 20080207651 and 20090221604, each of whichis hereby incorporated by reference in its entirety. Exemplary PGDSinclude, without limitation, ethyl3-(2-(3-fluorophenyl)pyrimidine-5-carboxamido)pyrrolidine-1-carboxylate,N-(1-(7,8-dihydro-5H-pyrano[4,3-d]pyrimidin-2-yl)pyrrolidin-3-yl)-2-(3-fluorophenyl)pyrimidine-5-carboxamide,2-(3-fluorophenyl)-N-{1-[(methylamino)carbonyl]piperidin-4-yl}pyrimidine-5-carboxamide,2-(3-fluorophenyl)-N-[1-(6-methyl-5,6,7,8-tetrahydropyrido[4,3-d]pyrimidin-2-yl)pyrrolidin-3-yl]pyrimidine-5-carboxamide,2-(3-fluorophenyl)-N-[1-(2,2,2-trifluoroethyl)piperidin-4-yl]pyrimidine-5-carboxamide,2-[4-(4-methoxyphenyl)piperazin-1-yl]-4-phenylthiazol-5-carboxylic acid,(E)-3-{2-[4-(4-methoxyphenyl)piperazin-1-yl]-4-phenylthiazol-5-yl}acrylicacid,3-{2-[4-(4-methoxyphenyl)piperazin-1-yl]-4-phenylthiazol-5-yl}propionicacid, [4-phenyl-2-(4-phenylpiperazin-1-yl)thiazole-5-yl]acetic acid,{2-[4-(2-methoxyphenyl)piperazine-1-yl]-4-phenylthiazol-5-yl}aceticacid, [2-(4-benzylpiperazin-1-yl)-4-phenylthiazol-5-yl]acetic acid,N-{2-[4-phenyl-2-(4-phenylpiperazin-1-yl)thiazol-5-yl]acetyl}methanesulphonamide,N-(3-{2-[4-(4-methoxyphenyl)piperazin-1-yl]-4-phenylthiazol-5-yl}propionyl)-benzenesulphonamide,N-(2-{2-[4-(4-methoxyphenyl)piperazine-1-yl]-4-phenylthiazol-5-yl}acetyl)-benzenesulphonamide,N-{2-[4-phenyl-2-(4-phenylpiperazin-1-yl)thiazole-5-yl]acetyl}benzenesulphonamide,4-phenyl-2-(4-phenylpiperidin-1-yl)thiazole-5-carboxylic acid,2-[4-(2-methoxyphenyl)piperazine-1-yl]-4-phenylthiazole-5-carboxylicacid,1-(4-methoxyphenyl)-4-[4-phenyl-5-(1H-tetrazol-5-yl)thiazol-2-yl]piperazine,{2-[4-(4-methoxyphenyl)piperazine-1-yl]-4-phenylthiazol-5-yl}aceticacid, or a pharmaceutically acceptable salt or solvate thereof. Anyother PGDS inhibitors, whether now known or hereafter developed, canalso be utilized in accordance with the present invention.

According to a fourth embodiment, the agent that interferes withhyaluronan synthesis is 15d-PGJ2, a homolog thereof, or a pro-drug thatis metabolized to form 15d-PGJ2 upon administration.

According to a fifth embodiment, the agent that interferes withhyaluronan synthesis is a PPARγ agonist. Exemplary PPARγ agonistsinclude, without limitation, cyclopentenone class prostaglandins such asthe native PPARγ agonist 15-deoxy-Δ12,14-Prostaglandin J2, members ofthe thiazolidinedione class of PPARγ agonists such as the glitazones,lysophosphatidic acid (“LPA”) or LPA derivatives (McIntyre et al., Proc.Natl. Acad. Sci. USA 100:131-136 (2003), which is hereby incorporated byreference in its entirety), members of the tyrosine-based class of PPARγagonists, members of the indole-derived class of PPARγ agonists, andcombinations thereof. Preferred thiazolidinediones and/or glitazonesinclude, without limitation, ciglitazone, troglitazone, pioglitazone,rosiglitazone, SB213068 (Smith Kline Beecham), GW1929, GW7845(Glaxo-Wellcome), and L-796449 (Merck). Suitable tyrosine-based agonistsinclude N-(2-benzylphenyl)-L-tyrosine compounds (Henke et al., J. Med.Chem. 41:5020-5036 (1998), which is hereby incorporated by reference inits entirety. Suitable indole-derived agonists include those disclosed,e.g., in Hanks, et al., Biorg. Med. Chem LLH 9(23):3329-3334 (1999),which is hereby incorporated by reference in its entirety. Any otherPPARγ agonists, whether now known or hereafter developed, can also beutilized in accordance with the present invention.

From the foregoing description, it is intended in certain embodimentsthat the agent that interferes with hyaluronan synthesis is not a PPARγagonist. In other embodiments, the agent that interferes with hyaluronansynthesis is one or more agents other than a PPARγ agonist, optionallyin combination with one or more PPARγ agonists.

According to a sixth embodiment, a combination of any two or more of theHAS2-specific RNAi agent, the PGDS, the DP antagonist, and the PPARγagonist can be administered together (in a single formulation) orconcurrently (in separate formulations).

The agent(s) that interferes with hyaluronan synthesis can beadministered using any suitable mode of delivery that is effective fordelivery the agent to the retro-ocular space, which is the site whereexcessive hyaluronan synthesis occurs in thyroid eye disease.

Exemplary modes of administration include, without limitation, orally,by inhalation, by intranasal or airway instillation, optically,intranasally, topically, transdermally, parenterally, subcutaneously,intravenous injection, intra-arterial injection, injection to theretro-ocular space, intradermal injection, intramuscular injection,intrapleural instillation, intraperitoneally injection,intraventricularly, intralesionally, by application to mucous membranes,or implantation of a sustained release vehicle.

The above-identified agents are preferably administered in the form ofpharmaceutical formulation that includes one or more of the activeagents, alone or in combination with one or more additional activeagents, together with a pharmaceutically acceptable carrier. The term“pharmaceutically acceptable carrier” refers to any suitable adjuvants,carriers, excipients, or stabilizers, and can be in solid or liquid formsuch as, tablets, capsules, powders, solutions, suspensions, oremulsions. The carrier is a preferably suitable for ophthalmic delivery.

Typically, the composition will contain from about 0.01 to 99 percent,preferably from about 20 to 75 percent of active agents, together withthe adjuvants, carriers and/or excipients.

One exemplary formulation is a solid composition containing one or moreagents that interfere with hyaluronan synthesis and a mucoadhesivesubstance in the conjunctival sac, wherein the adhesion strength of themucoadhesive substance is in the range of from 200 to 1000 g. The use ofsuch mucoadhesive substance for posterior optical drug delivery isdescribed in U.S. Patent Application Publ. No. 20090036552, which ishereby incorporated by reference in its entirety.

Another exemplary formulation is an injectable sustained-releaseformulation that includes one or more agents that interfere withhyaluronan synthesis and a nanosphere. The nanosphere contains aparticle that comprises a particle-forming component capable of forminga vesicle, and an agent-carrying component capable of forming a complexwith the therapeutic agent(s) via electrostatic charge-chargeinteraction or hydrophobic-hydrophobic interaction. The particle-formingcomponent has at least one head group moiety selected from a hydrophobichead group moiety, a polar head group moiety and a combination thereof.The agent-carrying component is a chemical entity that contains one ormore negatively or positively charged groups. The use of such ananosphere composition is described in U.S. Patent Application Publ. No.20080118500, which is hereby incorporated by reference in its entirety.

Tablets, capsules, and the like can also contain a binder such as gumtragacanth, acacia, corn starch, or gelatin; excipients such asdicalcium phosphate; a disintegrating agent such as corn starch, potatostarch, alginic acid; a lubricant such as magnesium stearate; and asweetening agent such as sucrose, lactose, or saccharin. When the dosageunit form is a capsule, it can contain, in addition to materials of theabove type, a liquid carrier such as a fatty oil.

Various other materials may be present as coatings or to modify thephysical form of the dosage unit. For instance, tablets can be coatedwith shellac, sugar, or both. A syrup can contain, in addition to activeingredient, sucrose as a sweetening agent, methyl and propylparabens aspreservatives, a dye, and flavoring such as cherry or orange flavor.

The active agent(s) may also be administered in injectable dosages bysolution or suspension of these materials in a physiologicallyacceptable diluent with a pharmaceutical adjuvant, carrier or excipient.Such adjuvants, carriers and/or excipients include, but are not limitedto, sterile liquids, such as water and oils, with or without theaddition of a surfactant and other pharmaceutically and physiologicallyacceptable components. Illustrative oils are those of petroleum, animal,vegetable, or synthetic origin, for example, peanut oil, soybean oil, ormineral oil. In general, water, saline, aqueous dextrose and relatedsugar solution, and glycols, such as propylene glycol or polyethyleneglycol, are preferred liquid carriers, particularly for injectablesolutions.

These active compounds may also be administered parenterally. Solutionsor suspensions of these active compounds can be prepared in watersuitably mixed with a surfactant such as hydroxypropylcellulose.Dispersions can also be prepared in glycerol, liquid polyethyleneglycols, and mixtures thereof in oils. Illustrative oils are those ofpetroleum, animal, vegetable, or synthetic origin, for example, peanutoil, soybean oil, or mineral oil. In general, water, saline, aqueousdextrose and related sugar solution, and glycols such as, propyleneglycol or polyethylene glycol, are preferred liquid carriers,particularly for injectable solutions. Under ordinary conditions ofstorage and use, these preparations contain a preservative to preventthe growth of microorganisms.

For use as aerosols, the compounds of the present invention in solutionor suspension may be packaged in a pressurized aerosol containertogether with suitable propellants, for example, hydrocarbon propellantslike propane, butane, or isobutane with conventional adjuvants. Thematerials of the present invention also may be administered in anon-pressurized form such as in a nebulizer or atomizer.

Transdermal formulations include, without limitation, a transdermaldelivery system, typically in the form of a patch that contains a depotof the active drug(s) in a pharmaceutically acceptable transdermalcarrier, or simply a solution phase carrier that is deposited onto theskin, where it is absorbed. A number of transdermal delivery systems areknown in the art, such as U.S. Pat. No. 6,149,935 to Chiang et al., PCTApplication Publ. No. WO2006091297 to Mitragotri et al., EP PatentApplication EP1674068 to Reed et al., PCT Application Publ. No.WO2006044206 to Kanios et al., PCT Application Publ. No. WO2006015299 toSantini et al., each of which is hereby incorporated by reference in itsentirety.

According to a further embodiment, which is suitable for implantation,the pharmaceutical formulation may be in the form of a polymeric matrixin which the agents to be administered are captured. Release of theagents can be controlled via selection of materials and the amount ofdrug loaded into the vehicle. Implantable drug delivery systems include,without limitation, microspheres, hydrogels, polymeric reservoirs,cholesterol matrices, polymeric systems, and non-polymeric systems. Anumber of suitable implantable delivery systems are known in the art,such as U.S. Pat. No. 6,464,687 to Ishikawa et al., U.S. Pat. No.6,074,673 to Guillen, each of which is hereby incorporated by referencein its entirety.

Preferred dosages of the above-identified agents are between about 0.001to about 2 mg/kg, preferably 0.05 to about 1 mg/kg, most preferablyabout 0.05 to about 0.5 mg/kg. Administration of the agents can berepeated as needed, e.g., up to several times daily during treatment ofTED and according to a periodic schedule (once weekly or up to severaltimes a week, including once daily) to inhibit recurrence of thyroid eyedisease.

The above-identified therapeutic treatments can also be used incombination with one or more current therapies, including withoutlimitation, radiation therapy, prednisone therapy, and surgicaldecompression.

The patients to be treated in accordance with the present invention canhave varying degrees of severity of TED. Consequently, it is expectedthat the degree of symptom control can constitute preventing furtherdevelopment of TED symptoms or a reduction in the severity of TEDsymptoms.

In certain embodiments, patients having TED can be those that have noother medical conditions, such as diabetes. In other embodiments,patients having TED can also be type 2 diabetic and receiving concurrenttreatment for their diabetes, including treatment with a PPARγ agonistsuch as one of the above-identified thiazolidinediones (e.g.,pioglitazone or rosiglitazone).

EXAMPLES

The following examples are provided to illustrate embodiments of thepresent invention but they are by no means intended to limit its scope.

Materials & Methods for Examples 1-7

Reagents

PGD₂, PGJ₂, MK0524, Ramatroban (BAY-u3405), BW 245C,4-benzhydryloxy-1-[3-(1H-tetrazol-5-yl)-propyl]-piperidine (HQL-79),13,14-dihydro-15-keto-PGD2 (DK-PGD₂); anti-DP1, anti-H-PGDS, anti-Cox-1,anti-Cox-2 antibodies were purchased from Cayman Chemical (Ann Arbor,Mich.). Forskolin, A23187 and isobutylmethyl-xanthine (IBMX) werepurchased from Sigma (St. Louis, Mo.). Anti-DP2 antibody was purchasedfrom R&D system (Minneapolis, Minn.). All the drugs were dissolved inDMSO.

Tissue Collection and Cell Culture

Orbital fibroblasts: Primary orbital fibroblasts were isolated from TEDpatients undergoing orbital decompression surgery. The protocols fororbital biopsy and blood sample, described below, were approved by theInternal Review Board and informed, written consent was obtained fromall patients. The primary fibroblasts were established by standardexplant techniques (Smith et al., J Clin Endocrinol Metab80(9):2620-2625 (1995); Baglole et al., Methods Mol Med 117:115-127(2005), each of which is hereby incorporated by reference in itsentirety) and cultured in RPMI 1640 supplemented with 10% fetal bovineserum (FBS) (Hyclone, Logan Utah), 2-mercaptoethanol (Eastman Kodak,Rochester, N.Y.), L-glutamine (Life Technologies, Grand Island, N.Y.),HEPES (US Biochemical Corp., Cleveland, Ohio), nonessential amino acids,sodium pyruvate, and gentamicin (Life Technologies). Fibroblasts werecharacterized by their adherent morphology, expression of vimentin andtypes I and III collagen and absence of CD45, factor VIII orcytokeratin. Fibroblasts were used at the earliest passage possible(between passages 4 to 10). Human T cells: Lymphocytes were isolatedfrom 60 ml of peripheral blood obtained during orbital decompressionsurgery. Whole blood was separated over a Ficoll-Paque Plus Gradient(Amersham Biosciences, Piscataway, N.J.) to obtain peripheral bloodmononuclear cells. T cells were enriched using CD3/CD28 T cell Expanderbeads (Invitogen). Specifically, 5×10⁶ lymphocytes were incubated withCD3/CD28 beads at a ratio 1:1 in RPMI 1640 with 10% FBS media at 37° C.for 2 days. After that, 50 U/ml of recombinant interleukin-2 (rIL-2) wasadded to the culture and incubated for another 2-3 days. On day 5, cellswere diluted to a concentration of 0.5×10⁶ cells/ml in medium containing50 U/ml rIL-2 and incubated for an additional 3-7 days. Cellular puritywas assessed using an anti-CD3-PE antibody (BD Biosciences, San Jose,Calif.) and analyzed on a FACSCalibur flow cytometer (BD Biosciences).The T-cell purity was >95%.

Co-Culture of Mast Cells with Orbital Fibroblasts

HMC-1 mast cells were allowed to proliferate in Iscove's ModifiedDulbecco's Medium (IMDM) enriched with 5% FBS. Co-cultures wereinitiated by introducing HMC-1 cells to confluent cultures offibroblasts as previously described (24). Mast cells were washed withRPMI-1640 medium (0.5% FBS) once before addition to the fibroblasts (1:1ratio, unless otherwise specified). After 4 hours, the media and HMC-1cells were removed by gently rinsing in PBS and fresh RPMI-1640 medium(0.5% FBS) was used to cover the cells. Alternatively, fibroblasts andmast cells were co-cultured in a transwell system (0.4 μm; GreinerBio-one, New York, N.Y.) with fibroblasts being cultured on the bottomand the mast cells in the top chamber. The ratio of mast cells tofibroblasts was varied from 5:1 to 20:1.

Quantitation of HA

Aliquots of culture medium were removed at indicated time points,centrifuged (5 min, 8,000×g at 4° C.) and HA levels quantified byenzyme-linked immunosorbent assay (ELISA) according to themanufacturer's protocol (R&D Systems). Briefly, samples were incubatedin HA-binding protein (HABP)-coated microwells, allowing HA in samplesto react with the immobilized HABP. After the removal of unboundmolecules by washing, biotinylated-HABP was added to the microwells.Following a second wash, streptavidin-conjugated to horseradishperoxidase was added. After the last wash, the chromogenic substrate wasadded and HA levels were determined using a Varioskan Flash plate reader(Thermo Fisher Scientific, Milford, Mass.).

Agarose Gel Electrophoresis of HA

Fibroblasts were cultured to confluence in 10 cm² dishes in RPMIcontaining 10% FBS, followed by RPMI with 2% FBS for 3 days. Fibroblastswere then treated with 5 μM PGD₂ or control (DMSO) for 18 hours. Cellculture supernatant was centrifuged (5 min at 8,000×g at 4° C.) and halfof the sample digested with 1 TRU/ml Streptomyces hyaluronidase (Sigma)at 37° C. for 4 hours; the remainder of the sample was mock-digested.Following digestion with proteinase K (120 μg/ml) (Qiagen, Valencia,Calif.) at 37° C. for 4 hours, the samples were concentrated usingVivaspin 10,000 Da cut-off ultrafiltration spin column (Sartorius StedimBiotech, Goettingen, Germany), washed with PBS and analyzed by 1%agarose electrophoresis. Select-HA HiLadder (Hyalose LLC, Oklahoma City,Okla.) and blue dextran (Sigma; molecular weight 2×10⁶ Da) were also runas standards. The gel was stained with 0.005% Stains-All (Sigma) in 50%ethanol overnight at room temperature before being scanned on an HPscanner.

Western Blotting

Following treatments, cells were lysed in 1×SDS sample buffer andprotein concentrations determined using the DC protein assay kit(Bio-Rad, Hercules, Calif.). Samples were separated on a 9% or 12%SDS-PAGE gel, transferred to polyvinylidene difluoride (PVDF) membranes,and subjected to immunoblotting with antibodies against DP1 (1:1,000),DP2 (1:500), H-PGDS (1:500), Cox-1 (1:500), or Cox-2 (1:500). As aloading control, membranes were re-probed for GAPDH (1:3000, Calbiochem,San Diego, Calif.).

Measurement of cAMP

cAMP levels were quantified using a time-resolved fluorescence resonanceenergy transfer (TR-FRET) immunoassay from Perkin Elmer (Waltham, Mass.)according to the manufacturer's protocol. Briefly, orbital fibroblastswere detached with a non-enzymatic cell dissociation solution (Versene,Invitrogen) and re-suspended in Stimulation Buffer (pH 7.4; 1×HBSSbuffer containing 5 mmol/L HEPES buffer and 0.01%-0.1% BSA) containing0.5 mM IBMX and labeled with the Alexa Fluor® 647-labeled anti-cAMPantibody. Finally, the cells were incubated with drugs at the indicatedtimes. Following addition of the detection buffer, the amount of cAMPsignal was measured.

Measurement of PGD₂

HMC-1 cells (1×10⁶/well) were seeded into 6-well plates and cultured inIMDM medium with 5% FBS in the absence or presence of HQL-79 (H-PGDSinhibitor, 100 μM) at 37° C. for 60 minutes. The cells were then washedand resuspended in RPMI 1640 medium with 0.5% FBS. After 2 hoursincubation, the cells were stimulated with 10 μM calcium ionophoreA23187 for 30 minutes. The culture media were collected and PGD₂ in thesupernatants was quantified by PGD₂-MOX EIA kits (Cayman Chemical).

Reverse Transcriptase PCR (RT-PCR) and Quantitative RT-PCR (qRT-PCR)

RNA was isolated from orbital fibroblasts or T cells using an RNeasyMini kit (Qiagen). RNA was reverse transcribed to cDNA using iScriptcDNA synthesis kit (Bio-Rad) and diluted 5-fold in RNase-free H₂O.Forward and reverse primers for each gene are shown in Table I. RT-PCR:The PCR reaction was performed using Qiagen Fast Cycling PCR kit for 30cycles in a Bio-Rad thermal cycler. The PCR product was visualized on a5% acrylamide gel stained with ethidium bromide. Amplifications withoutreverse transcriptase were carried out as negative controls. qRT-PCR:qRT-PCR was performed in a Bio-Rad iCycler containing B-R SYBR GreenSuperMix for IQ (Quanta Biosciences, Gaithersburg, Md.). Efficiency ofthe amplification was determined to be >90%.

TABLE I Gene Primer Sequence Size Has1Forward 5′-TGTGTATCCTGCATCAGCGGT-3′ 172 bP (NM-001523) (SEQ ID NO: 7)Reverse 5′-CTGGAGGTGTACTTGGTAGCATAACC-3′ (SEQ ID NO: 8) HAS2Forward 5′-GCCTCATCTGTGGAGATGGT-3′ 181 bP (NM-005328) (SEQ ID NO: 9)Reverse 5′-ATGCACTGAACACACCCAAA-3′ (SEQ ID NO: 10) HAS3Forward 5′-GGCATTATCAAGGCCACCTA-3′ 184 bP (NM-005329) (SEQ ID NO: 11)Reverse 5′- AGGCCAATGAAGTTCACCAC-3′ (SEQ ID NO: 12) DP1Forward 5′-TCTGCGCGCTACCTTTCATG-3′  84 bP (NM-000953) (SEQ ID NO: 13)Reverse 5′-TCCTCGTGGACCATCTGGATA-3′ (SEQ ID NO: 14) DP2Forward 5′-TTTCTCAACATGTTCGCCAG-3′ 131 bP (NM-004778) (SEQ ID NO: 15)Reverse 5′-AAGCACCAGGCAGACTTTGT-3′ (SEQ ID NO: 16) 7S RNAForward 5′-ACCACCAGGTTGCCTAAGGA-3′  68 bP (NR-002715) (SEQ ID NO: 17)Reverse 5′-CACGGGAGTTTTGACCTGCT-3′ (SEQ ID NO: 18)

Amplification of 7S ribosomal RNA was carried out for each cDNA (intriplicate) for normalization. Threshold cycle number (CO ofamplification in each sample was determined by Bio-Rad software and therelative mRNA abundance was calculated as the C_(t) for amplification ofa gene-specific cDNA minus average C_(t) for 7S, expressed as a power of2; i.e., 2^(ΔCt).

Gene Knockdown Using siRNA

Orbital fibroblasts were cultured to 80-90% confluence and transfectedwith 80 nM of HAS1, HAS2 or scrambled control (SC) siRNA (Santa Cruz)using Lipofectamine 2000 (Invitrogen). Forty eight hourspost-transfection, RPMI containing 0.5% FBS was added. Twenty-four hourslater, the cells were treated with or without 5 μM PGD₂ for 2 hours (forqRT-PCR analysis) or 18 hours (for analysis of HA secretion).

Statistical Analysis

Statistical analysis was performed using GraphPad Prism (GraphPadSoftware, Inc, La Jolla, Calif.). For comparison between groups of threeor more, an analysis of variance (ANOVA) with Newman-Keuls multiplecomparison test was used to determine differences between treatments.Error bars represent the standard deviation from the mean of triplicatesamples. A p value of less than 0.05 is considered significant. Allexperiments were performed at least three times.

Example 1—D and J Series Prostaglandins Induce HA Synthesis by HumanOrbital Fibroblasts

It was previously reported that PGD₂ and PGJ₂ induce adipogenesis inhuman orbital fibroblasts (Feldon et al., Am J Pathol 169(4):1183-1193(2006), which is hereby incorporated by reference in its entirety).Here, it was examined whether PGD₂ or PGJ₂ would also induce HAproduction. Two strains of human orbital fibroblasts (OF1 and OF2) fromtwo different TED patients were treated with increasing concentrationsof PGD₂ or PGJ₂ for 18 hours, and HA levels were detected in the cellculture supernatant by a commercial HA ELISA. FIG. 1A shows that basallevels of HA differed significantly between the two orbital fibroblaststrains (OF1: 1.9±1.4 ng/μg protein versus OF2: 0.5±0.6 ng/μg protein;#p<0.05). Treatment of the fibroblast strain designated OF1 with eitherPGJ₂ or PGD₂ resulted in significantly more HA production compared toOF2. PGD₂ and PGJ₂ also significantly increased HA synthesis by bothfibroblast strains in a dose-dependant manner, with 5 μM PGD₂ and 2 μMPGJ₂ yielding the largest induction (FIGS. 1A-B). Higher concentrationsof PGD₂ nor PGJ₂ did not result in a further increase in HA synthesis ineither of the two fibroblast strains. Therefore, most of the remainingexperiments were conducted using 5 μM PGD₂ or 2 μM PGJ₂.

Agarose gel electrophoresis was performed to analyze the molecularsize(s) of HA produced by the orbital fibroblasts. HA is an extremelyhigh molecular weight polysaccharide (approximately 10⁵-4×10⁶ Da) andcan be separated from other GAGs by ultrafiltration combined withagarose gel electrophoresis (Lee et al., Anal Biochem 219(2):278-287(1994), which is hereby incorporated by reference in its entirety). FIG.1C confirms the presence of HA in the cell culture media of twofibroblast strains (OF1 and OF2) (lanes 3-6). Treatment with PGD₂ (D₂)increased HA compared with vehicle (V) (Lanes 4 and 6 compared withLanes 3 and 5). OF1 also produces relatively more low molecular weight(MW) HA compared to OF2. Streptomyces hyaluronidase was used to digestthe HA in the samples. Unlike other hyaluronidases, this enzyme isspecific for hyaluronic acid and is inactive with chondroitin andchondroitin sulfate (Ohya et al., Biochim Biophys Acta 198(3):607-609(1970), which is hereby incorporated by reference in its entirety). TheStreptomyces hyaluronidase-digested sample (HA′ase, lane 7) did not showany staining, confirming the HA specificity of the assay. Together,these results demonstrate that orbital fibroblasts increase theproduction of HA when exposed to PGD₂.

Example 2—Differential Expression of PGD₂-Induced Hyaluronidase in TwoOrbital Fibroblast Strains

Hyaluronidases (HYAL1-3) depolymerize HA into low MW polymers (Noble,Matrix Biol 21(1):25-29 (2002), which is hereby incorporated byreference in its entirety). To determine if the apparent increase in lowMW HA in PGD₂-treated OF1 fibroblast strain might be the result ofincreased hyaluronidase expression, OF1 and OF2 were treated with 5 μMPGD₂ and hyaluronidase mRNA levels were assessed. There was asignificant induction in HYAL1, HYAL2 and HYAL3 mRNA following treatmentof OF1 with PGD₂ (FIG. 2). In contrast, OF2 failed to significantlyincrease hyaluronidase mRNA expression. The induction in hyaluronidasesin OF1 caused by PGD₂ was significantly greater than PGD₂-treated OF2HYAL mRNA levels (FIG. 2). These results are the first to demonstrateregulation of hyaluronidase mRNA by PGD₂ in human orbital fibroblasts.

Example 3—PGD₂ Induces Hyaluronan Synthase mRNA Expression in HumanOrbital Fibroblasts

The effect of PGD₂ on HAS mRNA expression also was assessed. FIG. 3Ashows that all three HAS genes are expressed in orbital fibroblasts. Inuntreated cells (vehicle), HAS1 mRNA is very low and scarcelydetectable. In contrast, HAS2 and HAS3 mRNA is relatively greater.Following 2 hours of PGD₂ treatment, the mRNA for all three HAS isoformsincreased significantly (FIG. 3A-D), with HAS1 exhibiting the greatestinduction. The increase in HAS1 at two hours was significantly greatercompared to either HAS2 or HAS3 (compare FIG. 3B with FIGS. 3C-D;###p<0.001). The mRNA for all three HAS isoforms declined rapidly, andby 16 hours there was no significant difference compared to untreated (0Hours). 7S ribosomal mRNA expression remained the same, regardless oftreatment (FIG. 3A, compare lanes 5 and 9) and was used to normalize theqRT-PCR results (FIGS. 3B-D).

Example 4—PGD₂-Induced HA Production by Orbital Fibroblasts is Dependenton HAS2 Expression

To verify whether or not HA synthesis was directly related to HASexpression, siRNA was used to selectively knock-down HAS1 or HAS2 mRNAlevels in fibroblasts that were treated with PGD₂. FIG. 4A shows thatsiRNA directed against HAS1 or HAS2 selectively and significantlyreduced (by approximately 75%-80% of mRNA levels) PGD₂-induced HAS1(open bars) and HAS2 (black bars), compared to the scrambled siRNA (SCsiRNA).

Orbital fibroblasts that were untreated (open bars) or treated with PGD₂(black bars) were then analyzed for HA after transfection with siRNAagainst HAS1 and/or HAS2 (FIG. 4B). Those fibroblasts transfected withthe SC siRNA exhibited a significant increase in HA synthesis inresponse to PGD₂ (FIG. 4B, compared with FIG. 1A). Despite thesignificant increase in HAS1 mRNA induced by PGD₂ (FIG. 3A-B),attenuation of HAS1 expression did not block PGD₂-induced HA production(FIG. 4B). In contrast, reduction in HAS2 mRNA expression significantlyreduced both untreated and PGD₂-induced HA production when compared tothe SC siRNA control (FIG. 4B). This reduction in HA synthesis in theHAS2 siRNA transfected, PGD₂-treated fibroblasts was not significantlydifferent compared to untreated SC-siRNA-transfected cells (ns, p=0.13).These data support that HAS2 is the dominant isoform responsible for theincreased HA synthesis by orbital fibroblasts in response to PGD₂.

Example 5—PGD₂ and PGJ₂ Induce HA Production in Human OrbitalFibroblasts Via DP1, but not DP2, Activation

Both PGD₂ and PGJ₂ can exert their biological functions via activationof DP1 or DP2 (Pettipher et al., Nat Rev Drug Discov 6(4):313-325(2007), which is hereby incorporated by reference in its entirety). Itwas therefore examined whether or not human orbital fibroblasts expressDP receptors. RT-PCR and western blot analysis revealed that orbitalfibroblasts (OF1 and OF2) express both DP1 and DP2 mRNA and protein,respectively (FIGS. 5A-B). Protein expression of DP1 and DP2 in orbitalfibroblasts was comparable to that of human T cells, which arewell-known to express DP receptors, particularly DP2 (Nagata et al.,FEBS Lett 459(2):195-199 (1999); Nagata et al., Prostaglandins LeukotEssent Fatty Acids 69(2-3):169-177 (2003), each of which is herebyincorporated by reference in its entirety). Both orbital fibroblaststrains (OF1 and OF2) expressed considerably more DP1 mRNA and proteincompared to DP2 (FIGS. 5A-B).

To determine which DP was involved in the PGD₂-mediated induction of HA,well-described selective pharmacological antagonists directed againsteither DP1 (MK-0524) (Sturino et al., J Med Chem 50(4):794-806 (2007);Leblanc et al., Bioorg Med Chem Lett 19(8):2125-2128 (2009), each ofwhich is hereby incorporated by reference in its entirety) or DP2(Ramatroban) (Pettipher et al., Nat Rev Drug Discov 6(4):313-325 (2007);Royer et al., Eur J Clin Invest 38(9):663-671 (2008), each of which ishereby incorporated by reference in its entirety) were utilized.Fibroblasts were untreated or were pretreated with either MK-0524 orRamatroban for 1 hour with or without PGD₂ or PGJ₂. FIG. 5C showsneither MK-0524 (MK) nor Ramatroban (RAM) influenced basal HA levels(ns, compared with untreated, open bar). Fibroblasts treated with eitherPGD₂ (5 μM) or PGJ₂ (2 μM) significantly increased HA synthesis (FIG.5C, compared with FIGS. 1A-B and 4B). Pretreatment with the DP1antagonist MK-0524 completely blocked the ability of both PGD₂ and PGJ₂to induce HA production in orbital fibroblasts. By contrast,pretreatment with the DP2 antagonist Ramatroban was unable to preventthe induction of HA by PGD₂ or PGJ₂. This demonstrates that DP1 is thedominant receptor subtype involved in the induction of HA by D and Jseries prostaglindins.

To confirm the importance of DP1 on the induction of HA in human orbitalfibroblasts, the selective DP1 agonist BW245C (Kabashima et al.,Prostaglandins Leukot Essent Fatty Acids 69(2-3):187-194 (2003), whichis hereby incorporated by reference in its entirety) was used to treatOF and then HAS mRNA expression and HA production was assessed. Theresults presented in FIGS. 5D-F demonstrate that treatment with BW245C(10 μM) significantly induced HAS mRNA expression. Here, there was asignificant increase in HAS1 and HAS2 mRNA expression as early as twohours (FIGS. 5D-E). HAS3 mRNA increased by 6 hours of exposure to BW245C(FIG. 5F). In addition, BW245C dose-dependently increased HA levels(FIG. 5G). At concentrations of 5 μM and 10 μM, there was a significantincrease in HA production, compared to untreated fibroblasts.

In contrast, the high-affinity selective DP2 agonist DK-PGD₂ (Cheng etal., Proc Natl Acad Sci USA 103(17):6682-6687 (2006); Yoshimura-Uchiyamaet al., Clin Exp Allergy 34(8):1283-1290 (2004); Hirai et al., J Exp Med193(2):255-261 (2001), each of which is hereby incorporated by referencein its entirety), in the low μM concentration range, did notsignificantly increase HA levels. Taken together, these data providestrong evidence that PGD₂ and PGJ₂ induce HA production in orbitalfibroblasts through activation of the DP1.

Example 6—DP1 Activation Boosts Intracellular cAMP to Increase HA byOrbital Fibroblasts

Activation of DP1, a Gs-protein coupled receptor, is known to lead to anincrease in intracellular cAMP. It was therefore explored whetheractivation of DP1 by PGD₂, and subsequent production of HA, wouldrequire the generation of cAMP. Intracellular cAMP was measuredfollowing treatment with PGD₂ and the DP1 agonist BW245C. Treatment withPGD₂ (5 μM) and BW245C (10 μM) significantly increased intracellularcAMP production within 15 to 30 minutes (FIG. 6A). cAMP levels remainedelevated through 60 minutes (FIG. 6A, black bars).

To investigate whether or not the elevation in intracellular levels ofcAMP was directly attributable to the increased HA production by orbitalfibroblasts, cells were treated with forskolin, which activates adenylylcyclase to augment intracellular levels of cAMP (Morris et al., ActaPhysiol Scand 181(4):369-373 (2004); Metzger et al.,Arzneimittelforschung 31(8):1248-1250 (1981), which is HerebyIncorporated by reference in its entirety). Forskolin alonesignificantly increased HA production compared to vehicle-treatedfibroblasts (FIG. 6B). Cells were treated with either PGD₂ or PGJ₂together with IBMX, a nonselective phosphodiesterase inhibitor thatboosts cAMP levels by preventing its degradation (Weinberg et al., JCell Biochem 108(1):207-215 (2009), which is hereby incorporated byreference in its entirety). IBMX, in conjunction with either PGD₂ orPGJ₂, significantly enhanced the ability of PGD₂ or PGJ₂ to generate HA(FIG. 6B). Collectively, these data support the belief that PGD₂ andPGJ₂, via activation of DP1 and generation of cAMP, increase in HAproduction in human orbital fibroblasts.

Example 7—Mast Cell-Derived PGD₂ Activates Orbital Fibroblasts toProduce HA Via HAS2

Mast cells are a key immune cell proposed to be involved in thepathogenesis of TED via their ability to activate fibroblasts. Mastcells are also a key cell type that produces PGD₂ in vivo. Based on theresults in the preceding examples, it was believed that mastcell-derived PGD₂ would increase HA production by orbital fibroblasts.

It was first determined whether human mast cells produce PGD₂ in vitro.HMC-1 cells, a commonly used human mast cell line (Kim et al., ToxicolIn Vitro 23(7):1215-1219 (2009); Margulis et al., J Immunol183(3):1739-1750 (2009), each of which is hereby incorporated byreference in its entirety), were used to first examine whether mastcells express H-PGDS. Western blot analysis of unstimulated HMC-1 cellsrevealed that these cells basally express both Cox-1 and H-PGDS, thehematopoietic-type PGDS (FIG. 7A). HMC-1 cells were then activated withA23187, a calcium ionophore (Kim et al., Toxicol In Vitro23(7):1215-1219 (2009), which is hereby incorporated by reference in itsentirety), in the presence or absence of HQL-79, a specific inhibitor ofH-PGDS (Kanaoka et al., Prostaglandins Leukot Essent Fatty Acids69(2-3):163-167 (2003); Aritake et al., J Biol Chem 281(22):15277-15286(2006), each of which is hereby incorporated by reference in itsentirety), and PGD₂ production determined. FIG. 7B demonstrates thatactivated HMC-1 cells significantly increase PGD₂ compared tounstimulated cells. Inhibition of H-PGDS with HQL-79 significantlyreduced the level of PGD₂ in activated HMC-1 cells (FIG. 7B).

Using co-culture, the association between mast cells, orbitalfibroblasts, and HA production was further investigated. First, orbitalfibroblasts were cultured with HMC-1 cells (at a ratio of 1:1) for 4hours. Following removal of the mast cells and addition of fresh media,the supernatant was collected for HA analysis. When fibroblasts and mastcells were cultured together, there was a significant increase HAproduction compared to fibroblasts alone (FIG. 8A, open versus blackbar, **p<0.001).

A transwell system was then tested, whereby orbital fibroblasts werephysically separated from HMC-1 cells. Following 24 hours of co-culture,conditioned media in both chambers was collected for HA ELISA. HA levelswere negligible in the chamber (upper) containing only the HMC-1 cells.HA production also did not increase as a consequence of increasing cellnumber (FIG. 8B, open bars), indicating that HMC-1 cells do not produceHA in significant quantities. In contrast, HA levels in the lowerchamber (orbital fibroblasts) were significantly higher than in theHMC-1 (upper) chamber (FIG. 8B; ###p<0.001 upper chamber compared tolower chamber). Co-culture of HMC-1 cells with orbital fibroblastssignificantly increased HA levels with increasing ratios of HMC-1:orbital fibroblasts. Thus, even when HMC-1 cells were physicallyseparated from fibroblasts, HA levels increased, suggesting that one ormore factors secreted by the HMC-1 cells drives HA synthesis byfibroblasts.

To determine if PGD₂ was the factor secreted by HMC-1 cells that wasresponsible for driving HA synthesis by orbital fibroblasts, HMC-1 cellswere pretreated with HQL-79 (to block PGD₂ synthesis) and then thesecells were added to the upper chamber of the transwell at a ratio 20:1(HMC-1: orbital fibroblast). FIG. 8C shows that treatment of HMC-1 cellswith HQL-79 significantly attenuated the production of HA by orbitalfibroblasts compared to treatment of HMC-1 cells with vehicle alone.These data demonstrate that PGD₂ secreted by mast cells plays a dominantrole in HA production by orbital fibroblasts during TED pathogenesis.

Finally, to determine whether HA production by co-culture of fibroblastswith mast cells was via HAS2, orbital fibroblasts were transfected withcontrol, HAS1 or HAS2 siRNA and the transfected fibroblasts wereco-cultured with the mast cells. As expected, co-culture withuntransfected fibroblasts with HMC-1 cell significantly increased HAproduction (FIG. 9). Transfection of fibroblasts with either controlsiRNA or HAS1 siRNA failed to attenuate HA production elicited byco-culture with HMC-1 mast cells. In contrast, transfection of orbitalfibroblasts with HAS2 siRNA significantly decreased HA production byorbital fibroblasts. Here, there was a significant decrease in HA levelsin basal (untransfected, no mast cells) as well as by fibroblastsco-cultured with HMC-1 cells (FIG. 9). Collectively, these datahighlight the dominant role of HAS2 in HA production elicited by mastcell-derived PGD₂.

Discussion of Examples 1-7

TED is a debilitating disorder that causes disfigurement and visionimpairment. TED afflicts approximately 40% of patients with Graves'hyperthyroidism, a thyroid-specific autoimmune disease characterized bythe presence of auto-antibodies against the thyroid-stimulating hormonereceptor. Treatment of moderate to severe TED often involves invasiveprocedures, including orbital radiotherapy and orbital decompressionsurgery (Bartalena et al., N Engl J Med 360(10):994-1001 (2009), whichis hereby incorporated by reference in its entirety). There are feweffective pharmacological treatments for TED due, in part, to a poorunderstanding the pathogenic mechanisms leading to clinicalmanifestations of TED. Current evidence suggests that activation oforbital fibroblasts by infiltrating inflammatory cells, particularly Tcells and mast cells, plays an important role in TED pathogenesis (Hwanget al., Invest Ophthalmol Vis Sci 50(5):2262-2268 (2009); Feldon et al.,Invest Ophthalmol Vis Sci 46(11):3913-3921 (2005); Lehmann et al.,Thyroid 18(9):959-965 (2008), each of which is hereby incorporated byreference in its entirety). Orbital fibroblast proliferation and ECMproduction, particularly HA (Feldon et al., Am J Pathol 169(4):1183-1193(2006); Gianoukakis et al., Endocrinology 148(1):54-62 (2007); Kaback etal., J Clin Endocrinol Metab 84(11):4079-4084 (1999), each of which ishereby incorporated by reference in its entirety), are key events thatcontribute to manifestations of TED, such as periorbital edema,exophthalmos and extraocular motility dysfunction (Prabhakar et al.,Endocr Rev 24(6):802-835 (2003); van Steensel et al., Invest OphthalmolVis Sci 50(7):3091-3098 (2009), which is hereby incorporated byreference in its entirety). The data from Examples 1-7 above providesubstantial evidence that mast cell-derived PGD₂ is a key factor thatregulates the production of HA by orbital fibroblasts via activation ofDP1 (FIGS. 1A-B, 5A-C, and 7B). Importantly, prevention of DP1 signaling(FIG. 5C) or PGD₂ production by mast cells (FIG. 8C) attenuated HAsynthesis by the fibroblasts.

HA is a large negatively charged polysaccharide that is overproduced inthe retroocular space of patients with TED (Kahaly et al., Thyroid8(5):429-432 (1998), which is hereby incorporated by reference in itsentirety). HA has remarkable viscosity and ability to retain water,which leads to increases in orbital tissue volume and anteriordisplacement of the eye, culminating in exophthalmos (Smith et al., JClin Endocrinol Metab 89(10):5076-5080 (2004), which is herebyincorporated by reference in its entirety). Fibroblasts are the majorsource of HA in the orbit. Activation of orbital fibroblasts byimmunoglobulins from TED patients (Smith et al., J Clin Endocrinol Metab89(10):5076-5080 (2004), which is hereby incorporated by reference inits entirety) and cytokines such as interleukin-10 (Kaback et al., JClin Endocrinol Metab 84(11):4079-4084 (1999), which is herebyincorporated by reference in its entirety), interferon-γ (Smith et al.,J Clin Endocrinol Metab 72(5):1169-1171 (1991), which is herebyincorporated by reference in its entirety) and transforming growthfactor-0 (Wang et al., J Cell Biochem 95(2):256-267 (2005), which ishereby incorporated by reference in its entirety) increase HAproduction. It is believed that the data presented in the precedingexamples are the first to show that PGD₂, a non-cytokine mediator,contributes to HA synthesis by orbital fibroblasts (FIGS. 1A-C). Theincrease in HA production by PGD₂ is directly related to increasedexpression of HAS2 (FIGS. 3A, 3C, 4B, and 9). Despite the fact that allthree HAS isoforms (HAS1, HAS2 and HAS3) are significantly increased,only the attenuation of HAS2 expression completely abrogatedPGD₂-induced HA. This is in agreement with observations made inHAS2^(−/−) mouse embryos, which are virtually devoid of HA (Camenisch etal., J Clin Invest 106(3):349-360 (2000), which is hereby incorporatedby reference in its entirety). Of interest, HAS1 mRNA exhibited the mostdramatic increase in response to PGD₂, yet does not contributesignificantly to HA biosynthesis (FIG. 4B). This observation may beexplained by the fact that HAS1 protein rapidly loses its enzymaticactivity (Itano et al., J Biol Chem 274(35):25085-25092 (1999), which ishereby incorporated by reference in its entirety). Thus, these dataprovide compelling evidence that HAS2 is responsible for most, if notall, HA production by orbital fibroblasts in response to PGD₂.

The induction of HAS mRNA, and subsequent production of HA, required thegeneration of the second messenger cAMP via activation of DP1. DPreceptors are expressed on orbital fibroblasts (FIGS. 5A-B); thisproperty of orbital fibroblasts was not previously known.Pharmacological activation of DP1 significantly increased HAS mRNA andHA biosynthesis (FIG. 5C). Moreover, the DP1 antagonist MK-0524completely inhibited PGD₂-induced HA production whereas DP2 antagonistRamatroban had no effect. These findings provide substantial evidencethat PGD₂-induced HA production is mediated solely by DP1. MK-0524 (alsoknown as Laropiprant and CORDAPTIVE™) is an orally-acting drug that iscurrently being developed in conjunction with niacin as acholesterol-lowering drug (Schwartz et al., Am J Ther 16(3):215-223(2009), which is hereby incorporated by reference in its entirety).These results indicate that selectively targeting the DP1 system (viaMK-0524 or any other similar acting pharmaceutical agents) in the eyeshould prevent the severity and/or occurrence of proptosis in TEDpatients by reducing HA production.

PGD₂ also regulates the migration of inflammatory cells by facilitatingvasodilatation and increasing vascular permeability (Ulven et al., CurrTop Med Chem 6(13):1427-1444 (2006), which is hereby incorporated byreference in its entirety). Within the eye, this would facilitatetransendothelial migration of infiltrating mast cells and lymphocytes,thereby contributing to the increase in immune cells characteristic ofTED. Association of mast cells with fibroblasts/adipocytes in theorbital tissue is commonly observed in biopsies of TED patients as wellas animal models of TED (Lauer et al., Ophthal Plast Reconstr Surg24(4):257-261 (2008); Boschi et al., Br J Ophthalmol 89(6):724-729(2005); Hufnagel et al., Ophthalmology 91(11):1411-1419 (1984); Many etal., J Immunol 162(8):4966-4974 (1999); Costagliola et al., J ClinInvest 105(6):803-811 (2000); Yamada et al., Autoimmunity 35(6):403-413(2002), each of which is hereby incorporated by reference in itsentirety). Mast cell degranulation and close proximity to adipocytes aresuggestive of their participation in the TED process (Boschi et al., BrJ Ophthalmol 89(6):724-729 (2005), which is hereby incorporated byreference in its entirety).

The data presented in the preceding examples strongly support the beliefthat mast cell:fibroblast interactions participate in TED. It was firstdemonstrated that fibroblasts robustly respond to PGD₂ to increase HAsynthesis (FIG. 1A). Using both a co-culture and transwell system, itwas also demonstrated that mast cells increase orbital fibroblastproduction of HA via PGD₂ produced by the mast cell (FIG. 8A-C). Thisaccumulated HA within the orbit can, in turn, facilitate inflammatorycell infiltration (Toole, Nat Rev Cancer 4(7):528-539 (2004), which ishereby incorporated by reference in its entirety) to the orbit, therebyperpetuating clinical symptoms associated with TED. These data highlightPGD₂ as a key regulator of orbital fibroblast function.

It has been well-described that fibroblasts are heterogeneous, differingnot only between organ systems but also within a given organ (Smith etal., J Clin Endocrinol Metab 80(9):2620-2625 (1995); Phipps et al., JPeriodontal Res 32(1 Pt 2):159-165; Borrello et al., Cell Immunol173(2):198-206 (1997); Hagood et al., Chest 120(1 Suppl):64S-66S (2001);Khoo et al., Thyroid 18(12):1291-1296 (2008), each of which is herebyincorporated by reference in its entirety). In a previously publicationit was shown that fibroblasts from the lung exhibit significantinter-individual variability in their apoptotic response to cigarettesmoke (Baglole et al., Am J Physiol Lung Cell Mol Physiol 291(1):L19-29(2006), which is hereby incorporated by reference in its entirety), afinding that may explain why only a fraction of smokers develop lungdiseases such as chronic obstructive pulmonary disease (COPD).Therefore, it is noteworthy that there was significant variability in HAproduction, HA size and HYAL expression between orbital fibroblastsderived from two different individuals (FIGS. 1A-C and FIG. 2). Theincrease in low MW HA by OF1 (FIG. 1B) correlates with increasedexpression of HYAL1-3 (FIG. 2). These enzymes are responsible for thedepolymerization of HA, thereby generating HA fragments (Noble, MatrixBiol 21(1):25-29 (2002), which is hereby incorporated by reference inits entirety). These low MW HA fragments are known to promoteinflammation (de la Motte et al., Am J Pathol 174(6):2254-2264 (2009),which is hereby incorporated by reference in its entirety) by activatingimmune cells and increasing inflammatory gene expression (Gao et al., JBiol Chem 283(10):6058-6066 (2008), which is hereby incorporated byreference in its entirety). Thus, increased HA production, coupled withthe generation of inflammation-promoting low MW HA, by orbitalfibroblasts from an individual could be a decisive factor in predictingwhich Graves' patients ultimately develop symptomatic TED.

Using a combination of molecular and pharmacological approaches, thedata presented herein illustrate a role for mast cell-derived PGD₂ inpromoting HA biosynthesis by orbital fibroblasts, key effector cells inthe pathogenesis of TED. The data also shows that the DP1/cAMP signalingpathway rapidly activates HAS mRNA induction to promote HA production.PGD₂, in addition to causing HA accumulation, may also provide anenvironment conducive of lymphocytes infiltration into orbital tissuevia DP1. The lymphocytic accumulation within the orbit may, in turn,lead to additional release of inflammatory mediators, including PGD₂.Therefore, selectively targeting the production of lipid mediators(i.e., PGD₂) and/or activation of receptor systems (DP1) should reduceor prevent symptoms associated with TED.

Materials and Methods for Example 8-15

Materials

Rosiglitazone and GW9662 were purchased from Cayman Chemical (Ann Arbor,Mich.). Pioglitazone HCL was purchased from ChemPacific (Baltimore,Md.). Recombinant human TGF-β1 was purchased from Calbiochem (EMDbioscience, La Jolla, Calif.). [³H] glucosamine hydrochloride waspurchased from PerkinElmer Life Sciences. Hyaluronic acid potassium saltfrom human umbilical cord and Streptomyces hyaluronidase (HA′ase) werepurchased from Sigma (St. Louis, Mo.). Unlike other hyaluronidases, thisenzyme is specific for HA and is not active with chondroitin andchondroitin sulfate substrates (Ohya et al., Biochim Biophys Acta.198(3):607-609 (1970), which is hereby incorporated by reference in itsentirety).

Tissue Collection and Orbital Fibroblast Cell Culture

Orbital fibroblasts: Primary orbital fibroblasts were isolated from TEDpatients undergoing orbital decompression surgery. The protocol fororbital biopsy and blood sample isolation, described below, was approvedby the Internal Review Board and informed, written consent was obtainedfrom all patients. The primary fibroblasts were established by standardexplant techniques (Smith et al., J Clin Endocrinol Metab 80(9):2620-2625 (1995); Baglole et al., Methods Mol Med 117:115-27 (2005),each of which is hereby incorporated by reference in its entirety) andcultured in RPMI 1640 supplemented with 10% fetal bovine serum (FBS)(Hyclone, Logan Utah), 2-mercaptoethanol (Eastman Kodak, Rochester,N.Y.), L-glutamine (Life Technologies, Grand Island, N.Y.), HEPES (USBiochemical Corp., Cleveland, Ohio), nonessential amino acids, sodiumpyruvate, and gentamicin (Life Technologies). Fibroblasts werecharacterized by their adherent morphology, expression of vimentin andcollagen (types I and III) and absence of CD45, factor VIII andcytokeratin. Fibroblasts were used at the earliest passage possible(between passages 4 to 10). Human peripheral blood T cells: One unit ofblood was obtained from healthy donors as approved by the University ofRochester Institutional Review Board and Office for Human SubjectsProtection. Peripheral blood mononuclear cells (PBMC) were obtained bydensity-gradient centrifugation of buffy coat using Ficoll-Paque Plus(Amersham Biosciences, Piscataway, N.J.). PBMCs were washed in PBS and Tcells were enriched using CD3/CD28 T cell Expander beads (Dynal Inc.,Brown Deer, Wis.). Specifically, 5×10⁶ PBMCs were incubated withCD3/CD28 beads at ratio 1:1 in RPMI1640 with 10% FBS medium at 37° C.for 2 days. After that, 50 U rIL-2/ml was added to the culture andincubated for another 2 or 3 days. On day 5, cells were diluted to0.5×10⁶/ml in culture medium containing 50 U/ml rIL-2 and incubated foranother 3-7 days according to the cell number. After T-cell expansion,the cells were examined for purity by staining with an anti-CD3phycoerythrin-labeled antibody (BD Biosciences, San Jose, Calif.). The Tcell purity was >95%.

Cell Viability Assay

Cell viability was assayed using the colorimetric XTT(2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide)assay kit (Roche, Germany). Briefly, orbital fibroblasts were seeded ina 96-well plate and cultured with various treatments. Twenty hours aftertreatment, 50 μl of XTT labeling mixture was added and cells wereincubated at 37° C. for 4 hours. The amount of cleaved XTT productgenerated by metabolically active cells was assayed by measuringabsorbance using an ELISA plate reader at 480 nm with a referencewavelength at 650 nm. Cell viability results were also confirmed byTrypan blue staining.

Flow Cytometry

Enriched human peripheral blood T lymphocytes were surface stained forCD3 (BD Biosciences, San Jose, Calif.) or CD44 (clone IM7, Biolegend,San Diego, Calif.) for 20 min at 4° C., washed in staining buffer (PBSwith 0.3% BSA) and pelleted by centrifugation. Samples were run on aFACScalibur (BD Bioscience, San Jose, Calif.) flow cytometer andanalyzed using FlowJo software (Tree Star).

Quantitation of HA

Confluent monolayers of orbital fibroblasts were serum starved in 0.5%FBS RPMI-1640 medium for three days and pretreated with differentconcentrations of Pio or Rosi for 1 hour and then treated with orwithout 2 ng/ml TGF-β1 for 24 hours. After treatments, an aliquot ofculture medium (secreted HA) was removed and centrifuged at 8,000×g at4° C. for 5 minutes and the supernatant was saved for later analysis.The cells were washed twice with PBS and treated with 0.25% trypsin-EDTAsolution (GIBCO, Invitrogen) at 37° C. for 5 minutes, the reaction wasstopped by addition of culture medium and cell number was determinedusing a hemocytometer. The cells were then centrifuged and thesupernatant was collected and incubated at 100° C. for 10 minutes toinactivate trypsin activity. This supernatant was saved for pericellularHA detection. The cell pellet was washed with PBS once and digested with120 μg/ml proteinase K in 0.1% SDS/0.1 M Tris-HCl (pH 7.6) at 37° C. for1 hour, and proteinase K was inactivated by incubation at 100° C. for 10min. The cell lysate was centrifuged and supernatant analyzed forintracellular HA.

The amount of HA in each extract (secreted HA, pericellular HA andintracellular HA) was measured by ELISA based on the specificinteraction of HA with HA binding protein (HABP). The HA detection kitwas purchased from R&D system (Minneapolis, Minn.). Briefly, dilutedsamples were incubated in HABP-coated microwells, allowing HA present insamples to react with the immobilized HABP. After extensive washing,biotinylated HABP was added to the microwells to form complexes withbound HA. Following another round of washing, streptavidin conjugatedhorseradish peroxidase was added. After a brief incubation period andwashing, chromogenic substrate was added and HA levels were determinedusing a Varioskan Flash plate reader (Thermo Fisher Scientific, Milford,Mass.). A fraction of the samples were pretreated with Streptomyceshyaluronidase (2 U/ml at 37° C. for 2 hour) before subjected to theELISA assay as a negative control. Furthermore, an additional 50 ng/ml(final concentration) of free soluble HA was added to a fraction of thecell lysate samples to confirm that there are no inhibitory factorspresent and that the assays show the expected additivity when a knownamount of exogenous HA is included.

HA [³H] Radiolabeling

Confluent monolayers of orbital fibroblasts were serum starved for threedays and treated with or without 2 ng/ml TGF-β1 for 24 hours. One hourafter TGF-β1 treatment, [³H] glucosamine hydrochloride (PerkinElmer LifeSciences) was added to the medium to a final concentration of 20 μCi/ml.After labeling, the medium, trypsin extract solution and cell lysatewere collected as described above. Radiolabeled macromolecules in eachextract were concentrated using a Vivaspin 10 kDa cut-offultrafiltration spin column (Sartorius Stedim Biotech, Goettingen,Germany) and washed with PBS twice. An equivalent radiolabeled aliquotwas digested with Streptomyces hyaluronidase (2 U/ml) at 37° C.overnight before concentration. The concentrated solution wastransferred to scintillation vials, and [³H] incorporation wasdetermined with a microplate scintillation counter (TopCount;PerkinElmer, Meriden, Conn.). Incorporation of [³H]-glucosamine into HAwas calculated by subtracting the counts from the Streptomyceshyaluronidase digested fraction.

T Cell Adhesion Assay

Preparation of peripheral blood mononuclear T cells. Enriched T cells(1×10⁷ cells/ml) were fluorescently labeled by incubation withcalcein-AM (10 μg/ml, Molecular Probes) for 45 min in RPMI 1640 mediumwithout phenol red, and washed twice in RPMI 1640 medium with 0.5% FBS.After labeling, some T cells were incubated with monoclonal CD44antibody (clone IM7, Biolegend, San Diego, Calif.) or isotype (RatIgG2b) at dilution of 1:25 (final concentration is 40 μg/ml) at 37° C.for 15 minutes. Preparation of orbital fibroblasts. Confluent orbitalfibroblasts in a 96-well plate were serum starved and incubated withdifferent concentrations of Pio or Rosi treated with or without 2 ng/mlTGF 1 for 24 hours. In some cultures, orbital fibroblasts were treatedwith Streptomyces hyaluronidase (100 mU/ml at 37° C. for 1 hour) priorto the adhesion assay to deplete endogenous HA. Adhesion Test.Immediately before the adhesion assay, the conditioned medium of orbitalfibroblasts was removed to eliminate treatments and secreted ECM.1×10⁵/well of Calcein AM labeled T cells were added to a 96-well platewith a confluent orbital fibroblast monolayer and allowed to adhere for90 min at 4° C. as previously described. Plates were washed three timeswith the addition of 200 ul of PBS followed by plate inversion andgentle tapping to remove the wash solution. Fluorescence was measuredwith an excitation of 485 nm and detection of 535 nm, in a VarioskanFlash plate reader (Thermo Electron Corporation). There is a positivecorrelation between the labeled T cell number and fluorescence intensity(r² is >0.998), thus the number of T cells bound per well was calculatedfrom the fluorescence intensity of the well.

Immunohistology

Orbital fibroblasts were cultured in 8-chamber slides (BD REF354108) andfixed in room temperature 3% paraformaldehyde in PBS and stained with 1μg/ml biotinylated HABP (Seikagaku, Cape Cod) followed by Cy3-conjugatedstreptavidin (Jackson laboratories, West Grove, Pa.). F-actin wasstained with Phalloidin (Molecular Probes). In some cultures, orbitalfibroblasts were treated with Streptomyces hyaluronidase prior tostaining. T cells were stained with an anti-CD3 monoclonal antibody(clone UCHT, SouthernBiotech, Birmingham, Ala.) followed by a goatanti-mouse antibody labeled with Alexa-488 (Molecular Probes). DAPI (10μg/ml, Anaspec, San Jose, Calif.) was used for nuclear staining.

Orbital adipose tissues were obtained from TED patients undergoingorbital decompression surgery. The tissues were fixed in 3%paraformaldehyde in PBS at 4° C. for 1 hour and washed with PBS. Tissueswere then saturated in 20% sucrose/PBS at 37° C. for 2 hours, embeddedin OCT compound (Sakura Tissue Tek) and frozen in dry ice. Ten μm thicksections of frozen tissue were first incubated with biotinylated HABP,anti-CD44 and anti-CD3 monoclonal antibodies and the stained withCy3-conjugated streptavidin, Alexa-488 conjugated donkey anti-ratantibody and Alexa-647 conjugated goat anti-mouse antibody. Somesections were pretreated with 2 U/ml Streptomyces hyaluronidase beforestaining or were added free soluble HA 200 m/ml to HABP probe to competeendogenous HA as HA negative control. Fat was stained with Bodipy493/503 dye (Molecular Probes). Slides were photographed using a CarlZeiss Axio Imager M1 Microscope.

Reverse Transcriptase PCR (RT-PCR) and Quantitative RT-PCR (qRT-PCR)

RNA was isolated from orbital fibroblast strains using the RNeasy Minikit according to the manufacturer's protocol (Qiagen, Valencia, Calif.)and reverse transcripted to cDNA using iScript cDNA synthesis kit(Bio-Rad, Hercules, Calif.). Primers for human HAS1, 2, 3 and 7S as wellas qRT-PCR method to detect relative abundance of mRNA are identifiedsupra. Primers for human PPARγ1 (NM138711) and PPARγ 2 (NM015869) mRNAwere 5′-AAAGAAGCCGA-CACTAAACC-3′ (SEQ ID NO:3) (sense),5′-CTTCCATTACGG-AGAGATCC-3′ (SEQ ID NO:4) (antisense) and,5′-GCGATTC-CTTCACTGATAC-3′ (SEQ ID NO:5) (sense),5′-CTTCCATT-ACGGAGAGATCC-3′ (SEQ ID NO:6) (antisense), respectively.

mRNA Knockdown Using Small Interfering RNA (siRNA)

Orbital fibroblasts were cultured to 80-90% confluence and transfectedwith PPARγ SMARTpool siRNA and scramble control (SC) siRNA (Dharmacon).Final concentration of siRNA was 80 nM using Lipofectamine 2000(Invitrogen) according to the instructions of the manufacturer.Forty-eight hours after transfection, the cells were serum starved for48 hours and the medium was replaced with fresh medium containing 2ng/ml TGF-β1, either with or without 10 μM Pio or 10 μM Rosi. After 24hours incubation, the medium was collected and HA levels were analyzedby ELISA. For PPARγ mRNA detection, four days after transfection, RNAwas prepared as above and PPARγ1 and PPARγ 2 mRNA levels were analyzedusing Real-Time PCR. HAS1 and HAS2 siRNAs (Santa Cruz) were also used toknockdown HAS1 and HAS2 mRNA expression, respectively, as describedsupra. After 24 hours transfection, the cells were serum starved andtreated with TGF-β1 for 24 hours before further experiment.

Statistical Analysis

Statistical analysis was performed using GraphPad Prism (GraphPadSoftware, Inc, La Jolla, Calif.). For comparison between groups of threeor more, an analysis of variance (ANOVA) with a Newman-Keuls multiplecomparison test was used to determine differences between treatments.Error bars represent the standard deviation from the mean of triplicatesamples. A p value<0.05 is considered significant. All experiments wereperformed at least three times.

Example 8—TGF-β1 Induces HA Synthesis and Pio and Rosi Inhibit TGF-β1Induced HA Biosynthesis in Human Orbital Fibroblasts

To determine whether the PPARγ ligands Pio and Rosi might block TGF-β1induced HA synthesis, several representative primary human orbitalfibroblast strains were selected and then treated with 2 ng/ml TGF-β1 inthe presence or absence of the PPARγ ligands Pio or Rosi at varyingconcentrations. Representative results from two fibroblast strain areshow in FIG. 10A. HA, which is synthesized on the plasma membrane, canbe secreted into the ECM, stay on the cell membrane or remain in thecell. HA levels were detected in the cell culture supernatant (secretedHA), in cell trypsin solution (pericellular HA), and in cell lysate(intracellular HA) using a commercial HA ELISA kit. FIG. 10Ademonstrates that TGF-β1 significantly increased secreted andpericellular HA levels (p<0.001, upper and middle panel), respectively,but had no effect on intracellular HA levels (lower panel). In strain#1,TGF-β1 increased secreted HA levels 12.16±0.15 fold and increasedpericellular HA levels 8.34±1.33 fold compared to vehicle control. Therewas 2.31±0.36 fold more secreted HA compared with pericellular HA infibroblasts treated with TGF-β1. Strain#2 showed similar results (FIG.10A). Therefore about 70% of the TGF-β1 mediated, newly synthesized HAwas secreted into the ECM. The remaining newly synthesized HA waslocalized pericellularly on the cell surface. FIG. 10A also demonstratesthat Pio or Rosi treatment alone has no significant effect on HAsynthesis. However, treatment with Pio and Rosi substantially diminishedthe induction of secreted HA and pericellular HA by TGF-β1 in adose-response manner. 10 μM Pio inhibited TGF-β1 mediated secretion andpericellular accumulation of HA by a 52±2.2% and 40±2.2%, respectively.Experiments using 10 μM Rosi instead of 10 μM Pio showed similar results(FIG. 10A). However, 20 μM Rosi significantly reduced intracellular HAlevels in both strains.

To confirm the HA ELISA results, ³H-glucosamine, which is incorporatedinto newly synthesized HA, was used to compare HA levels betweencell-associated and secreted HA levels. The results showed similarincreases in HA accumulation.

Immunofluorescence was also used to analyze HA expression. FIG. 10Bshows untreated cells (top row) with HA staining (green) mainly aroundthe nucleus. In TGF-β1 treated cells (middle row), HA staining is morepronounced and forms microvillus-like protrusions (Kultti et al., J BiolChem 281(23):15821-15828 (2006), which is hereby incorporated byreference in its entirety). Cells treated with Streptomyceshyaluronidase before immunostaining (bottom row) did not show HAstaining and furthermore did not affect stress fiber F-actin staining(red) or nuclear staining (blue), confirming specificity of theexperiment. TGF-β1 treatment did not significantly alter F-actin levelsor affect cell structure in this system as cells were only treated withTGF-β1 for 24 hours.

Example 9—Pio and Rosi Inhibit TGF-β1 Induced HAS1 and HAS2 mRNAExpression

The preceding examples demonstrate that increased HA production by PGD₂is directly related to increased expression of HAS2 (FIGS. 3A, 3C, 4B,and 9).

To determine if the PPARγ ligands Pio and Rosi could inhibit TGF-β1induced increases in HAS mRNA levels, fibroblasts were treated with 2ng/ml TGF-β1 with or without Pio or Rosi for 6 hours and RNA wasisolated and HAS expression was determined by Real-Time PCR. FIG. 11shows that TGF-β1 strongly induced HAS1 and HAS2 mRNA levels, whichincreased about 50- and 6-fold, respectively, while HAS3 mRNA levelsremained unchanged. Pio treatment significantly inhibited TGF-β1-inducedHAS1 mRNA expression in a dose dependent manner, whereas Rosi treatmentinhibited HAS1 mRNA expression similarly at both doses used (FIG. 11,top graph). Both Pio and Rosi treatment significantly inhibitedTGF-β-induced HAS2 mRNA expression in a dose-dependent manner (FIG. 11,middle graph). 10 μM Pio inhibited TGF-β1 mediated HAS1 and HAS2 mRNAinduction by approximately 50%. 10 μM Rosi had similar effects on HAS1and HAS2 mRNA levels (FIG. 11).

Example 10—Pio and Rosi do not Influence Orbital Fibroblast Viability

To rule out the possibility that the reduction in HA synthesis is aresult of toxicity by Pio and Rosi, viability of human orbitalfibroblasts treated with the PPARγ ligands was measured by the XTTassay. Viable cells actively cleave the XTT reagent and form a watersoluble orange formazan dye, the appearance of which is proportionate tothe number of viable cells. As FIG. 12 demonstrates, after 24 hourstreatment, there was no significant difference in cell viability amongtreatment conditions, with or without addition of TGF-β1. Furthermore,in the experiment for FIG. 10, cells were counted after each treatmentto normalize HA production per cell. No significant changes in cellnumber were detected from cells treated with Pio or Rosi. Thus, therewas no evidence of cell toxicity in orbital fibroblasts exposed to Pioand Rosi at the concentrations used.

Example 11—Pio and Rosi Inhibit TGF-β1 Induced HA Production Via aPPARγ-Independent Pathway

One potential mechanism by which Pio and Rosi treatment decrease TGF-131induced HA production is through activation of PPARγ, since they arePPARγ ligands and PPARγ acts as a negative regulator of TGF-β (Sime, JInvestig Med 56(2):534-538 (2008), which is hereby incorporated byreference in its entirety). GW9662 is a highly specific PPARγ antagonistthat covalently binds to a cysteine residue within the ligand bindingdomain of PPARγ, permanently altering its ability to bind its ligands(Ferguson et al., Am J Respir Cell Mol Biol 41:722-731 (2009), which ishereby incorporated by reference in its entirety). It was previouslyreported that PPARγ ligand-driven adipogenesis is PPARγ dependent and iscompletely inhibited by GW9662 (Feldon et al., Am J Pathol169(4):1183-11893 (2006), which is hereby incorporated by reference inits entirety). However, the addition of GW9662 did not significantlyreduce the ability of either Pio or Rosi to inhibit TGF-β1 induced HAsynthesis (FIG. 13A), providing compelling evidence that Pio and Rosifunction through molecular pathways that are independent of PPARγactivation.

To confirm this result using a genetic approach, PPARγ specific siRNAswere introduced into orbital fibroblasts to downregulate PPARγexpression. Real-Time PCR demonstrated that PPARγ 1 and PPARγ 2 mRNAlevels were decreased by more than 90% in PPARγ siRNA treated samplescompared to control siRNA treated samples (FIG. 13B). PPARγ siRNA alsoinhibited orbital fibroblast adipogenesis driven by PPARγ ligands asdemonstrated by oil red 0 staining. However, PPARγ siRNA did notinfluence HA production in orbital fibroblasts treated with or withoutTGF-β1 compared to control siRNA, and did not prevent the inhibition ofTGF-β1 mediated HA production by Pio and Rosi (FIG. 13C). These dataprovide further evidence that Pio and Rosi mediated effects on HAproduction are PPARγ-independent.

Example 12—TGF-β1 Treated Orbital Fibroblasts Bind Activated Human TCells Through HA-CD44 Interaction

One of the hallmarks of TED is the infiltration of leukocytes(particularly T cells) into orbital tissue. Extracellular HA binds thecell surface receptor CD44 and promotes lymphocyte rolling and adhesionto sites of inflammation. Therefore, increased production of HA mediatedby TGF-β1 prompted investigation of the possibility that TGF-β1 promotesT cell adhesion to orbital fibroblasts. Human peripheral blood T cellswere activated using IL-2 and enriched by CD3/CD28 beads. The expressionof CD44 and CD3 (T cell marker) were detected by flow-cytometry. FIG.14A demonstrates that about 99% of the enriched human T cells are CD44and CD3 positive, indicating that T cells have the potential to bind HAproduced by orbital fibroblasts.

Next, the T cell adhesion assay was performed with human orbitalfibroblasts. Orbital fibroblasts were treated with or without TGF-β1 for24 hours. To eliminate the influence of TGF-β1 or other factors inconditioned medium, fresh medium was added to fibroblast culturesimmediately before addition of T cells. To determine if HA is associatedwith the adhesion of T cells, a fraction of TGF-β1 treated fibroblastcultures were incubated with Streptomyces hyaluronidase to digestextracellular HA and a fraction of T cells were incubated with amonoclonal CD44 antibody or an isotype control to block the HA-CD44binding site. T cells were pre-labeled with calcein-AM and added tofibroblast cultures and allowed to incubate at 4° C. for 90 minutes.FIG. 14B shows that adhesion of T cells to orbital fibroblasts treatedwith TGF-β1 significantly increased compared to untreated controlfibroblasts. T cells preincubated with CD44 antibody adhered less tofibroblasts than did T cells preincubated with isotype control antibody(FIG. 14B, third bar, p<0.01). As another control, T cells wereincubated with exogenous HA at 37° C. for 1 hour before being added toorbital fibroblasts. As expected, addition of 100 or 500 μg/ml exogenousHA significantly reduced T cell adhesion to orbital fibroblasts.Furthermore, pretreatment of fibroblast cultures with Streptomyceshyaluronidase, which completely digests extracellular HA, abolishedTGF-β1-induced T cell adhesion (FIG. 14B, fifth bar, p<0.01). These dataindicate that newly synthesized pericellular HA is required forcell-cell adhesion and that the HA-CD44 interaction plays an importantrole in T cell adhesion to orbital tissue. A non-fibroblast control wasused to confirm that the binding is through cell-cell adhesion, not acell-substratum adhesion.

Example 13—TGF-β1 Induced Adhesion of Orbital Fibroblasts and ActivatedHuman T Cells was Attenuated by HAS2 mRNA Knockdown

In Examples 1-7 it was demonstrated that HAS2 is the dominant isoformresponsible for increased HA synthesis by orbital fibroblasts inresponse to PGD₂. To test the involvement of HAS enzymes in the TGF-βmediated response, siRNA was used to selectively knock down HAS1 or HAS2mRNA levels in fibroblasts. FIG. 15A shows that siRNA directed againstHAS1 (open bars) or HAS2 (shaded bars) selectively and significantlyreduced (by ˜65-80% of mRNA levels) TGF-β-induced HAS1 and HAS2,compared with the scrambled control (SC) siRNA (black bars). Inaddition, the marked upregulation of secreted HA and pericellular HA inresponse to TGF-β1 was inhibited by HAS2 mRNA knockdown, but HAS1knockdown had little effect (FIG. 15A). These data confirm the precedingexamples showing that HAS2 is the dominant isoform in orbitalfibroblasts. T cell adhesion to orbital fibroblasts that were untreated(open bars) or treated with TGF-β1 (black bars) after transfection withsiRNAs for HAS1, HAS2 or SC siRNA was also analyzed. As expected, HAS2knockdown significantly reduced T cell adhesion to orbital fibroblasts(FIG. 15B), further indicating that HA is required for T cell-orbitalfibroblast adhesion.

Example 14—Pio and Rosi Inhibit TGF-β1 Induced T-Cell Adhesion toOrbital Fibroblasts

Since Pio and Rosi attenuate TGF-β1 induced HA synthesis, and HAmediates fibroblast and T cell adhesion, it was expected that Pio andRosi might prevent TGF-β1 induced fibroblast-T cell adhesion.Fibroblasts were treated with different concentrations of Pio or Rositogether with TGF-β1. After 24 hours of treatment, the conditionedmedium was removed to eliminate the influence of TGF-β1 and drugs on Tcells and fresh medium was added along with the T cell suspension. Aspredicted, FIG. 16A demonstrates that fibroblasts pretreated with Pio orRosi had significantly reduced ability to adhere to T cells compared tofibroblasts treated with TGF-β1 only. Immunostaining was used to confirmthe adhesion assay results. T cells stained with the T cell marker CD3(green) colocalize with fibroblasts and are associated with HA stainedwith biotinylated HABP (red) (FIG. 16B). TGF-β1 treated fibroblastsadhere to a greater number of T cells (FIG. 16B, panel c) than do TGF-β1treated fibroblasts pretreated with Pio or Rosi (FIG. 16B, panel for i,respectively).

Example 15—CD44⁺/CD3⁺ Cells Infiltrate Graves' Orbital Adipose Tissue

The accumulation of GAGs and infiltration of inflammatory cells intoorbital tissues are prominent histological markers of TED. Theinfiltration of T cells in Graves' orbital adipose tissue was furtherinvestigated using immunofluorescence on orbital tissue sections.Orbital adipose tissues were obtained from TED patients undergoingorbital decompression surgery as described in materials and methods. Thetissue sections were stained with CD44 and CD3 antibodies, biotinylatedHABP for HA staining, and DAPI for nuclear staining. FIG. 17 shows thatCD44 (green) and CD3 (purple) are colocalized in small round cells (Tcells). Concentrated infiltration of CD44⁺/CD3⁺ cells is visible in theadipose sections (FIG. 17, panels b, c, f and g). HA staining is shownby narrow red bands outlining large vacuoles that indicate fat dropletdeposits (FIG. 17, panel a). Addition of free soluble HA to the HABPprobe completely eliminated HA staining (FIG. 17, panel e), suggestingthat the HA staining is specific. CD44⁺/CD3⁺ cells are clustered aroundthe vessel area and are attached to the vessel wall or just outside thevessel, suggesting that CD44⁺/CD3⁺ cells were traversing through thevessel wall to the orbital tissue (FIG. 17, panels f and g, see arrows).Fat droplets were stained with Bodipy 493/503 dye and CD3⁺ cells couldbe found among the green fat droplets.

Discussion of Examples 8-15

Orbital fibroblasts are believed to be the primary autoimmune target inTED (Bahn, N Engl J Med 362(8):726-738 (2010); Bahn et al., N Engl JMed., 329(20):1468-1475 (1993), each of which is hereby incorporated byreference in its entirety). Once orbital fibroblasts become activated,they undergo proliferation, differentiation and/or produce GAGs. Theaccumulation of GAGs, especially the hydrophilic GAG, HA, is the mostevident feature of tissue remodeling in TED. Although TGF-β levels areincreased in human orbital tissue and TGF-β increases HA secretion intothe culture medium of orbital fibroblasts in vitro (van Steensel et al.,Invest Ophthalmol Vis Sci. 50(7):3091-3098 (2009); Wang et al., J CellBiochem. 95(2):256-67 (2005), each of which is hereby incorporated byreference in its entirety), the data presented in the preceding examplesdemonstrates for the first time that TGF-β induced accumulation of HA isnot only secreted HA, but also pericellular HA (HA remaining on the cellsurface). The increased HA levels mediated by TGF-β are most likely dueto increased levels of HAS2 mRNA in orbital fibroblasts. Furthermore,TGF-β also increases the adhesion of activated T cells to orbitalfibroblasts mediated by newly synthesized pericellular HA on orbitalfibroblasts interacting with its cognate receptor CD44 on T cells.

The infiltration of orbital tissue by inflammatory cells (such as Tcells, B cells, mast cells, and macrophages) and the accumulation of HAare two histological characteristics of TED (Lehmann et al., Thyroid18(9):959-965 (2008), which is hereby incorporated by reference in itsentirety). Surprisingly, the correlation between the two features is notclear. HA is a multifunctional ECM molecule that participates inregulation of inflammation and tissue remodeling. It is well documentedthat the HA-CD44 interaction can play a pro-inflammatory role infacilitating leukocyte recruitment and adhesion to inflammatory sites.Previous studies show that CD44 is expressed at elevated levels inGraves' orbital connective tissue in situ (Heufelder et al., Med Klin(Munich) 88(4):181-184, 277 (1993), which is hereby incorporated byreference in its entirety), suggesting a role for HA/CD44 in regulatinginflammatory responses in TED. The results presented in the precedingexamples demonstrate that CD44⁺ cells are present in Graves' orbitaltissue sections and that these cells express the T cell marker CD3.These results also show that TGF-β induced HA-rich pericellular matrixfacilitates orbital fibroblast adhesion to activated T cells. Theadhesion of fibroblasts and T cells depends on the HA-CD44 interactionsince: (1) activated human T cells highly express CD44 (FIG. 14A); (2)pre-incubation of T cells with CD44 antibody significantly reduced Tcell adhesion to fibroblasts (FIG. 14B); (3) pre-treatment of thefibroblasts with Streptomyces hyaluronidase to digest HA diminishedcell-cell adhesion (FIG. 14B); and (4) HAS2 siRNA blocked HA synthesisand significantly inhibited cell-cell adhesion (FIG. 15B); and (5) CD44⁺T cells appear to attach to orbital fibroblasts with increasespericellular HA (FIG. 16B). Importantly, these data indicate that theaccumulation of HA in orbital tissue not only contributes to periorbitaledema, but also participates in the inflammatory response by enhancingor facilitating inflammatory cell infiltration into orbital tissue.

Recent work reveals that PPARγ and its ligands have anti-inflammatoryand anti-TGF-β activities. Overexpression of PPARγ suppressesTGF-β-induced activation of monocytes/macrophages and fibrosis in humansubconjunctival fibroblasts (Saika et al., Am J Physiol Cell Physiol.293(1):C75-86 (2007); Yamanaka et al., Invest Ophthalmol Vis Sci.50(1):187-193 (2009), each of which is hereby incorporated by referencein its entirety). TZDs and other PPARγ ligands such as 15d-PGJ₂ andCDDO, also show strong anti-TGF-β functions through PPARγ-dependent orindependent pathways (Burgess et al., Am J Physiol Lung Cell MolPhysiol. 288(6):L1146-53 (2005); Ferguson et al., Am J Respir Cell MolBiol 41:722-730 (2009); Guo et al., Diabetes 53(1):200-208 (2004), eachof which is hereby incorporated by reference in its entirety).Circulating levels of the chemokine CXCL10 and the cytokine interferongamma (IFNγ) are elevated in patients with Graves' Disease, particularlyin those with active TED. Rosi and Pio exert a dose-dependent inhibitionof IFNγ and Tumor Necrosis Factor-alpha (TNFα)-induced chemokines CXCL9,CXCL10 and CXCL11 secretion in orbital fibroblasts, preadipocytes andthyrocytes (Antonelli et al., J Clin Endocrinol Metab. 91(2):614-620(2006); Antonelli et al., J Clin Endocrinol Metab 94(5):1803-1809(2009), which is hereby incorporated by reference in its entirety).While these studies indicate that PPARγ activity is involved in theregulation of IFNγ induced chemokine expression in thyroid autoimmunityand TED, and PPARγ activators might attenuate the recruitment ofactivated T cells at sites of T helper type 1 (Th1)-mediatedinflammation, the preceding examples quite surprisingly demonstrate thatthe activity of PPARγ ligands Pio and Rosi in the context of the presentinvention occurs via a PPARγ-independent mechanism.

Both Pio and Rosi inhibit TGF-β mediated functions including: elevatingHAS1 and HAS2 mRNA levels, HA production, and T cell-fibroblastadhesion. However, in the experimental systems employed neither a PPARγantagonist GW9662 nor PPARγ knockdown relieve the inhibition of HAinduction by Pio and Rosi. The possibility of a PPARγ-independentmechanism for the Pio and Rosi mediated reduction of TGF-β activity wasunexpected. Therefore, several signaling pathways were evaluated toidentify a potential mechanism whereby TGF-β driven HA synthesis isinhibited by Pio and Rosi in the experimental system employed. However,there was no clear evidence showing that Pio or Rosi are generalinhibitors of TGF-β-induced responses in orbital fibroblasts. Forexample, the phosphorylation and nuclear translocation of Smad2 and 3induced by TGF-β was unaffected by co-treatment with Pio or Rosi.Furthermore, Pio and Rosi did not inhibit the TGF-β-activatedmitogen-activated protein kinase (MAPK) signaling pathway or thephosphorylation of p38 and p42/44. Other alternative pathways of TGF-βsuch as phosphorylation of AKT, c-jun N-terminal kinase (JNK) or c-Ablwere not detectable after TGF-β treatment in orbital fibroblast.

Despite these results, several case reports have described developmentof exophthalmos in patients receiving TZD treatment for type 2 diabetes(Levin et al., Arch Ophthalmol 123(1):119-121 (2005); Lee et al., BMCOphthalmol 7:8. (2007); Dorkhan et al., Clin Endocrinol (Oxf)65(1):35-39 (2006); Starkey et al., J Clin Endocrinol Metab 88(1):55-59(2003), each of which is hereby incorporated by reference in itsentirety). Since the results of these clinical studies are from TEDpatients with type 2 diabetes, the increase in exophthalmos might be theresult of adipocyte accumulation due to a pre-existing hyperinsulinaemicstate (Dorkhan et al., Clin Endocrinol (Oxf) 65(1):35-39 (2006), whichis hereby incorporated by reference in its entirety). Furthermore, thesuccess of TZD drugs as a therapy for type 2 diabetes is alsoparadoxical, as they target PPARγ, which induces adipose tissueformation, a major risk factor for type 2 diabetes (Lehrke et al., Cell123(6):993-999 (2005), which is hereby incorporated by reference in itsentirety).

Taken together, Examples 8-15 demonstrate that TGF-β plays an importantrole in human orbital fibroblast HA synthesis and the accumulation of HAin orbital tissue not only contributes to periorbital edema, but alsoparticipates in inflammatory responses by enhancing or facilitatinginflammatory cell infiltration into orbital tissue. Furthermore, thePPARγ ligands Pio and Rosi have strong inhibitory effects onTGF-β-mediated inflammatory processes and their mode of action isPPARγ-independent. Because these PPARγ ligands operate by a differentmechanism in down-regulating HA expression, these and other PPARγligands may be especially useful in combination therapies with one ormore of HAS2 RNAi, an inhibitor of PGDS, and a DP1 antagonist for thetreatment or prevention of TED.

Example 16—15-Deoxy-Δ12,14-Prostaglandin J2 (15d-PGD2) Inhibits TGF-β1Induced HA Secretion in a Dose-Dependent Manner

15-deoxy-412,14-Prostaglandin J2 (15d-PGD2) is an endogenous PPARγligand that exhibits diverse biological effects, includinganti-inflammatory and anti-fibrogenic activities. Given the demonstratedresults in the preceding examples, in this example it is demonstratedthat 15d-PGD2 inhibits TGF-β-mediated HA secretion in orbitalfibroblasts.

Primary orbital fibroblasts were isolated from Graves' disease patientsundergoing orbital decompression surgery. The cells were grown in RPMI1640 media containing 10% FBS, and incubated for 24 hours either with orwithout 2 ng/ml TGF-β1, and 0.5 μM, 1.0 μM, or 2.0 μM 15d-PGD2. Theamount of HA in the cell culture supernatant and pericellular extractionwas measured by ELISA as in the preceding Examples. While 15d-PGD2enhanced TGF-β induced HAS1 mRNA expression, it inhibited TGF-β inducedHAS2 mRNA expression. While TGF-β normally induces both HAS1 and HAS2mRNA expression, TGF-β induced HA secretion was inhibited by 15d-PGJ2(FIG. 18). Similar results were obtained with respect to pericellularHA.

These data reveal that 15d-PGJ2 is a potent inhibitor of TGF-β mediatedpro-inflammatory and fibrogenic activities in orbital fibroblasts. Newlysynthesized HA plays an impotent role in T cell-fibroblast adhesion. Theability to block HA synthesis with inhibitors such as 15d-PGJ2,therefore, presents an additional agent for therapeutic treatment ofTED.

Although preferred embodiments have been depicted and described indetail herein, it will be apparent to those skilled in the relevant artthat various modifications, additions, substitutions, and the like canbe made without departing from the spirit of the invention and these aretherefore considered to be within the scope of the invention as definedin the claims which follow.

What is claimed is:
 1. A method of treating thyroid eye disease comprising: selecting a patient having thyroid eye disease and administering to the selected patient a composition comprising an agent that interferes with hyaluronan synthesis in an amount that is effective to inhibit hyaluronan synthesis in a retro-ocular space, wherein the agent is 4-benzhydryloxy-1-[3-(1H-tetrazol-5-yl)-propyl]-piperidine (HQL-79), ethyl 3-(2-(3-fluorophenyl)pyrimidine-5-carboxamido)pyrrolidine-1-carboxylate, N-(1-(7,8-dihydro-5H-pyrano[4,3-d]pyrimidin-2-yl)pyrrolidin-3-yl)-2-(3-fluorophenyl)pyrimidine-5-carboxamide, 2-(3-fluorophenyl)-N-{1-[(methylamino)carbonyl]piperidin-4-yl}pyrimidine-5-carboxamide, 2-(3-fluorophenyl)-N-[1-(6-methyl-5,6,7,8-tetrahydropyrido[4,3-d]pyrimidin-2-yl)pyrrolidin-3-yl]pyrimidine-5-carboxamide, or 2-(3-fluorophenyl)-N-[1-(2,2,2-trifluoroethyl)piperidin-4-yl]pyrimidine-5-carboxamide.
 2. The method according to claim 1, wherein the composition comprises a PPARγ ligand, wherein the PPARγ ligand is 15-deoxy-Δ12,14-Prostaglandin J2 or a thiazolidinedione.
 3. The method according to claim 1, wherein said administering is carried out by injecting the agent into the retro-ocular space or application of a composition comprising the agent onto a surface of the patient's eye.
 4. The method according to claim 1, wherein the composition is a pharmaceutical composition further comprising a carrier selected from the group consisting of a liquid, suspension, polymeric delivery vehicle, mucoadhesive substance, and nanosphere.
 5. The method according to claim 1, wherein the agent that interferes with hyaluronan synthesis is 4-benzhydryloxy-1-[3-(1H-tetrazol-5-yl)-propyl]-piperidine (HQL-79). 